hypnosis in the treatment of chronic pain-an …

HYPNOSIS IN THE TREATMENT OF CHRONIC PAIN- AN ECOSYSTEMIC

APPROACH

by

CATHERINE PHYLLIS GOSSER

submitted in part fulfilment of the requirements for

the degree of

MASTER OF ARTS

in the subject

PSYCHOLOGY

at the

UNIVERSITY OF SOUTH AFRICA

SUPERVISOR: PROF DP FOURIE

NOVEMBER 2001

ii

ACKNOWLEDGEMENTS

My heartfelt thanks to

Professor Fourie for your wisdom and inspiration

My parents for their support and encouragement. I couldn't have done it

without you.

David and Stephen: my centre

Madri and Kobus for always being there for me

iii

TABLE OF CONTENTS

CHAPTER 1: INTRODUCTION

1.1 Chronic Pain

1.2 Hypnosis and pain

CHAPTER 2: HYPNOSIS:THEORETICAL BACKGOUND

AND RESEARCH FINDINGS

2.1 Theoretical background

2.1.1 Traditional Positivist Approaches

2.1.2 The Ecosystemic Approach

2.2 Research findings

CHAPTER 3: RESEARCH DESIGN

3.1 A case study approach

3.2 The sample

3.3 Variables

3.4 Measuring Instruments

3.5 Method

3.6 Validity

3. 7 Analysis of data

3.8 Possible problems

CHAPTER 4: RESEARCH RESULTS

4.1 Mandy

4.2 Dudu

4.3 Eve

4.4 Mike

4.5 Nick

4.6 Hannes

4. 7 Conclusion

1

6

12

12

21

30

36

37

39

40

55

60

62

63

66

93

109

125

143

157

164

iv

CHAPTER 5: CONCLUSION 165

REFERENCES 171

APPENDICES

Appendix A: Letter to physiotherapists 187

Appendix B: Letter to research participants 188

Appendix C: Brief Pain Inventory 190

LIST OF FIGURES

Figure 4.1 First completion of the BPI by Mandy: Pain

at worst rating 77

Figure 4.2: First completion of the BPI by Mandy: Pain

Interference score 77

Figure 4.3 Second completion of the BPI by Mandy: Pain

at worst rating 79

Figure 4.4 Second completion of the BPI by Mandy: Pain


Figure 4.5 Third completion of the BPI by Mandy: Pain

at worst rating 81

Figure 4.6 Third completion of the BPI by Mandy: Pain


Figure 4.7 Fourth completion of the BPI by Mandy: Pain at worst rating 85

Figure 4.8 Fourth completion of the BPI by Mandy: Pain


Figure 4.9 Fifth completion of the BPI by Mandy: Pain

at worst rating 87

Figure 4.10 Fifth completion of the BPI by Mandy: Pain


Figure 4.11 Sixth completion of the BPI by Mandy: Pain

at worst rating 89

Figure 4.12 Sixth completion of the BPI by Mandy: Pain

v


Figure 4.13 First completion of the BPI by Dudu: Pain

at worst rating 97

Figure 4.14 First completion of the BPI by Dudu: Pain


Figure 4.15 Second completion of the BPI by Dudu: Pain

at worst rating 98

Figure 4.16 Second completion of the BPI by Dudu: Pain


Figure 4.17 Third completion of the BPI by Dudu: Pain

at worst rating 100

Figure 4.18 Third completion of the BPI by Dudu: Pain


Figure 4.19 Fourth completion of the BPI by Dudu: Pain

at worst rating 102

Figure 4.20 Fourth completion of the BPI by Dudu: Pain


Figure 4.21 Fifth completion of the BPI by Dudu: Pain

at worst rating 105

Figure 4.22 Fifth completion of the BPI by Dudu: Pain


Figure 4.23 Sixth completion of the BPI by Dudu: Pain

at worst rating 107

Figure 4.24 Sixth completion of the BPI by Dudu: Pain


Figure 4.25 First completion of the BPI by Eve: Pain

at worst rating 113

Figure 4.26 First completion of the BPI by Eve: Pain


Figure 4.27 Second completion of the BPI by Eve: Pain

at worst rating 114

Figure 4.28 Second completion of the BPI by Eve: Pain

vi


Figure 4.29 Third completion of the BPI by Eve: Pain

at worst rating 117

Figure 4.30 Third completion of the BPI by Eve: Pain


Figure 4.31 Fourth completion of the BPI by Eve: Pain

at worst rating 119

Figure 4.32 Fourth completion of the BPI by Eve: Pain


Figure 4.33 Fifth completion of the BPI by Eve: Pain

at worst rating 120

Figure 4.34 Fifth completion of the BPI by Eve: Pain


Figure 4.35 Sixth completion of the BPI by Eve: Pain

at worst rating 122

Figure 4.36 Sixth completion of the BPI by Eve: Pain


Figure 4.37 First completion of the BPI by Mike: Pain

at worst rating 129

Figure 4.38 First completion of the BPI by Mike: Pain


Figure 4.39 Second completion of the BPI by Mike: Pain

at worst rating 131

Figure 4.40 Second completion of the BPI by Mike: Pain


Figure 4.41 Third completion of the BPI by Mike: Pain

at worst rating 133

Figure 4.42 Third completion of the BPI by Mike: Pain


Figure 4.43 Fourth completion of the BPI by Mike: Pain

at worst rating 135

Figure 4.44 Fourth completion of the BPI by Mike: Pain


Figure 4.45 Fifth completion of the BPI by Mike: Pain

vii

at worst rating 139

Figure 4.46 Fifth completion of the BPI by Mike: Pain


Figure 4.47 Sixth completion of the BPI by Mike: Pain

at worst rating 141

Figure 4.48 Sixth completion of the BPI by Mike: Pain


Figure 4.49 First completion of the BPI by Nick: Pain

at worst rating 148

Figure 4.50 First completion of the BPI by Nick: Pain


Figure 4.51 Second completion of the BPI by Nick: Pain

at worst rating 149

Figure 4.52 Second completion of the BPI by Nick: Pain


Figure 4.53 Third completion of the BPI by Nick: Pain

at worst rating 151

Figure 4.54 Third completion of the BPI by Nick: Pain


Figure 4.55 Fourth completion of the BPI by Nick: Pain

at worst rating 154

Figure 4.56 Fourth completion of the BPI by Nick: Pain


Figure 4.57 Fifth completion of the BPI by Nick: Pain

at worst rating 155

Figure 4.58 Fifth completion of the BPI by Nick: Pain


Figure 4.59 First completion of the BPI by Hannes: Pain

at worst rating 162

Figure 4.60 First completion of the BPI by Hannes: Pain


viii

SUMMARY

In this study, the use of hypnosis in the treatment of chronic low back pain is

described in terms of Ecosystemic thinking, as opposed to traditional

conceptualisations of hypnosis. Six case studies were used. Each is

described in detail, as well as the therapeutic rationale behind each case, in

order to present the reader with an understanding of the thinking behind using

Ecosystemic hypnotherapy.

Key terms:

Pain; Chronic pain; Chronic low back pain; Treatment of chronic pain;

Therapeutic rationale; Case studies; Hypnosis; Ecosystemic hypnotherapy;

Ecosystemic perspective

1.1 Chronic pain

CHAPTER 1

INTRODUCTION

Pain is easily one of the most common health problems today. According to

Bishop ( 1994), up to 80% of all visits to physicians involve pain-related

complaints. Bishop (1994) states that chronic pain can be categorised into

three main types, namely chronic periodic pain, chronic intractable benign

pain, and chronic progressive pain.

Chronic periodic pain is pain that is acute, but intermittent. For example a

person who suffers from migraine headaches may have excruciating

headaches that last for hours or days, but then may have several pain-free

weeks or months.

Chronic progressive pain is found, for example, in cancer patients. The

person experiences continuous pain that becomes worse as the disease

progresses.

Chronic intractable benign pain is present most of the time, with varying

intensity. One of the most common examples of this category is low back

pain. People who suffer from low back pain generally experience their pain

continually and find they can do little to reduce it.

The current study focuses on chronic low back pain sufferers. According to

Belar and Kibrick (1986), over 18 million Americans suffer from chronic painful

1

back disorders. They cite National Centre for Health Statistics which estimate

that in the United States approximately ten million outpatient visits are made

to non-federally employed physicians each year for back pain, almost one

million more visits than for upper respiratory infections.

The monetary impact of back pain on society is enormous. Maniadakis and

Gray (2000) conducted a study into the socio-economic costs of back pain in

the UK. They found that, although back pain may not be a life threatening

condition, it constitutes a major public health problem in Western

industrialized societies and exhibits epidemic proportions. Back pain is a

leading reason for physician visits, hospitalizations and other health and

social care service utilization in the UK. Maniadakis and Gray (2000) report

that in 1994-1995, 116 million production days were lost due to incapacity to

work related to back pain.

Macfarlane, Thomas, Croft, Papageorgiou, Jayson and Silman (1999) state

that the cost of back pain in the US is $25 billion in direct medical costs.

According to Macfarlane et al. (1999), as much as 80% of the population in

the US is affected by low back pain symptoms at some time in their lives.

Hutubessy, van Tulder, Vondeling and Bouter (1999) state that in the

Netherlands, the direct health care costs of musculoskeletal diseases in 1988

were the fourth highest, accounting for 6.6% of the total health care costs in

that year.

2

No data for the prevalence of chronic pain in South Africa currently exists.

Nevertheless, there is little reason to suppose that, in proportional terms, the

figures for South Africa are any different from those in any other industrialized

nation.

What are the costs for the individual who suffers from low back pain? Banks

and Kerns (1996) state that chronic pain is psychologically different from

acute or occasionally recurrent pain in meaningful ways. In the first place,

chronic pain amounts to quantitatively more aversive stimulation than acute

pain and is, therefore, likely to be more stressful psychologically. According to

Banks and Kerns (1996, p.103) chronic exposure to pain can "tax cognitive,

behavioural and emotional resources in terms of the demands that it makes

on the sufferer to conceive of and implement cognitive and behavioural coping

strategies, as well as to tolerate the pain emotionally".

Pinsky (in Roy, 1989, p. 3) in describing chronic intractable benign pain lists

the following phenomena:

• Mood and affect changes that are in themselves significantly dysphoric

• Drug dependency or abuse, of varying severities with their attendant CNS

effects

• Multiple surgeries and pharmacological treatments with their own morbid

side effects, separate form the drug dependency issues

• Escalating psychosocial withdrawal with increased loss of gratification from

normal social interactions

• Interpersonal conflicts with significant others

3

• Increasing hopelessness and helplessness as increasing dysphoria is not

relieved by mounting numbers of newer or different therapies

• Decrease in feelings of self-esteem, self-worth and self-confidence

• Decreasing ability to take pleasure from the life process, contributing to

profound demoralization and, at times, significant anhedonia, if not

depression

• Escalating physical incapacities secondary to the complaint of pain

because of fear of increasing pain, discomfort, and the fear of causing

more bodily harm, based on the belief that their ongoing pain is a signal of

increasing bodily damage

• Conflicts with medical care delivery personnel with resulting dissatisfaction

and/or hostilities

What impact does chronic pain have on the family? According to Roy (1985a,

p.305) "the presence of a chronic pain patient in a family system is highly

disruptive." Roy (1986, p.113) states that "a well-functioning family can, in a

reasonably short time, become almost totally dysfunctional when one of its

members gradually assumes the role of a chronic pain patient."

According to Roy (1989), the research literature on the impact of chronic pain

on the family has addressed the following issues:

1. Heightened psychological distress in the spouses of chronic pain sufferers

2. Compromised and less satisfactory sex life

3. Changes in roles resulting in additional responsibilities for other family

members, especially the spouse

4

4. Changes in communication patterns with multiple consequences, such as

reinforcement of pain behaviour, the loss of ability to communicate openly

and directly, and increased collusion

5. A heightened level of general marital distress

The spouse and the children are likely to feel a great deal of confusion about

the true nature of the pain problem. The family may feel the chronic pain

sufferer is imagining the pain because, as far as they can ascertain, there is

no organic problem. The family is often uncertain as to how to treat the

chronic pain sufferer and what to realistically expect from him/her. The chronic

pain sufferer's spouse may also feel the loss of a partner with whom he/she

can share thoughts and feelings because the person is irritable and/or

depressed most of the time.

Chronic pain thus has far reaching implications: economically at a national

level, for the individual sufferer and for his/her family. The current study

describes the impact of chronic pain on each participant and his/her family

system. Although a considerable body of literature exists which does address

the effects of chronic pain on the family system, these effects are different or

manifest in a different combination for each individual. From an ecosystemic

perspective it is vital to examine how chronic pain is embedded in each

individual participant's total ecology and to consider the possible meaning of

and function served by each participant's pain before embarking on treatment.

5

1.2 Hypnosis and pain

The application of mesmerism to surgical pain emerged early in the 19th

century when effective clinical techniques for pain management had not yet

been developed (Chaves & Dworkin, 1997). Mesmer himself began applying

his techniques to clinical pain and early reports of the Abbe di Faria (1819)

described the application of mesmerism to pain and hinted at its application in

surgery (Chaves & Dworkin, 1997).

There is some dispute about when hypnosis was first applied to the relief of

surgical pain. An undocumented account of a mastectomy by M.Dubois in

1797 and later reports of surgical procedures by Recamier were followed by

the first documented report of a mastectomy by Cloquet in 1829 (Chaves &

Dworkin, 1997). Evans (1990) tells us that the Scottish physician, James

Esdaile, documented the use of hypnosis in the control of pain. In the late

nineteenth century, just prior to the development of chemical anaesthesia,

Esdaile used hypnosis widely in India as the only form of anaesthesia for

amputations, tumour removals, and other complex surgical procedures. Most

of Esdaile's patients survived surgery, which was a rare event in those days

because of factors such as haemorrhage, shock and post-surgical infection.

With the advent of chemical anaesthetics, the need for and interest in

hypnotic analgesia declined. The newly discovered inhalation anaesthesia

was disseminated and won professional acceptance, despite the significant

number of fatalities attributed to it. Many authors (Barber, 1977; de Escobar,

6

1985; Jackson & Middleton, 1978) have, however, pointed out that there are

still advantages to hypnotic analgesia and hypnotic anaesthesia. It has none

of the side effects or dangers of chemical analgesics and anaesthetics,

especially when they are contraindicated due to specific medical or personal

conditions. In addition, hypnosis as an adjunct for pain control can

significantly reduce the amount of drugs needed (Chaves & Barber, 1976;

Harmon, Hynan & Tyre, 1990; Morse, 1977).

The use of hypnotic analgesia has been documented for dental procedures,

including routine fillings, root canal treatments, and extractions (Morse, 1977;

Morse, Schoor & Cohen, 1984; Toth, 1985). It has also been used for, among

other things, the removal of cancerous tumours (Perry & Laurence, 1983),

caesarean sections, abdominal explorations, prostrate operations, biopsies

(Chaves & Barber, 1976), gastrointestinal endoscopies (Jackson & Middleton,

1978), the surgical correction of ankyloglossia or "tongue tie" (de Escobar,

1985), and for post-operative pain following cancer surgery (Weiss, 1993).

Hypnotic analgesia has been employed to assist in pain management,

including the management of chronic head, neck and back pain (Bills, 1993).

Holroyd (1996) cites three studies that employed hypnosis, namely Haanen's

1991 study into fibromyalgia; Patterson, Everett, Burns and Marvin's study in

1992 with burn patients; and Syrjala, Cummings and Donaldson's clinical trial

in 1992, which used hypnosis for the reduction of pain and nausea in cancer

patients receiving bone marrow transplants.

7

Large (1995) reviews a number of controlled studies using hypnosis for

chronic pain conditions. These include Prior's 1990 study of irritable bowel

syndrome, Stam's work in 1984 with patients with temporomandibular pain,

Olness's study in 1987 with children with classic migraine, and Van Dyck's

1991 study with tension headaches.

The issue most commonly raised in the literature about hypnotic pain control

is a search for the mechanism(s) responsible for its functioning. Attempts to

deal with this issue fall into several categories, including dissociation theory

(Miller & Bowers, 1983), neodissociation theory (Hilgard, 1973), role theory

(Hilgard, 1973), psychoanalytic ego theory (Hilgard, 1973), trance logic (Perry

& Laurence, 1983), and the mediating effects of various neurochemicals,

including norepinephrine and endorphins (Jackson & Middleton, 1978;

Kihlstrom, 1985).

Thus far there appears to be a great deal of uncertainty concerning the

mechanism at work in hypnotic analgesia, and it appears unlikely that clarity

will be reached soon, if at all. The commonality in the traditional approaches

to hypnotic analgesia is that they all adhere to a positivist or Newtonian

epistemology that emphasises reductionism, linear causality and objectivity of

observation (Fourie & Lifschitz, 1989). Within this paradigm, the search for a

mechanism appears to be turning into a holy grail.

It may thus be useful to consider the subject of hypnotic analgesia from a

completely different paradigm, in order to gain a new perspective on the

8

subject. Rather than trying to find an explanatory mechanism internal to the

hypnotic subject, as has been the case in most of the literature, the

explanation will be situated within the ecosystemic paradigm, which

emphasises the process between all participants and the way in which the

meaning of behaviour is generated in order to influence experiences of reality.

Fourie and Lifschitz (1989) posit the following implications of an ecosystemic

conceptualisation of hypnosis and hypnotherapy: hypnosis is a concept, not

an entity; hypnotic behaviours are not caused; hypnotic behaviours exist

within a domain of consensus; hypnotic induction is a punctuating ritual;

hypnotic responsiveness is contextually specified; and hypnotic depth is a

culturally shaped subjective experience. From an ecosystemic point of view

hypnosis can be defined as a "a concept that describes a situation in which all

participants expect the subject to perform behaviours in such a way and of

such a nature that they are understood by everybody to be hypnotic" (Fourie,

1988, p.144).

The current study examined the effect that hypnosis, approached from an

ecosystemic perspective, can have on the chronic low back pain sufferer and

his/her family system. Although some successes have been reported using

hypnosis for pain conditions, none of these studies, with the exception of a

study by Bassett (1992), have approached the use of hypnosis with chronic

pain patients from an ecosystemic perspective. This study proposes that such

an approach is vital because the experience of chronic pain is so individual

and has to be considered in terms of the context in which it is embedded.

9

The above-mentioned study conducted by Bassett ( 1992) with chronic pain

patients did employ an ecosystemic approach to hypnosis. For several

reasons, however, no definite conclusions could be drawn with regard to the

efficacy of hypnosis, approached from an ecosystemic perspective, for such

patients. Although Bassett worked with chronic pain patients, no specific

category of chronic pain was specified. The researcher also did not stipulate

that the participants should already have exhausted the usual medical route

and should not be in need of any new medical or surgical intervention. As a

result the final participants had widely differing pain complaints and also

presented with other medical problems, such as problems with bladder and

bowel control, which complicated the treatment of the chronic pain problem. A

further problem is that Bassett was left with only two case studies out of the

original 14 recruits so that no conclusion could be drawn as to the possible

efficacy of this form of treatment.

The current study was not interested in the etiology of pain. As Capra (1983)

states, in practice it is frequently impossible to know which sources of pain are

physical and which psychological. According to Fourie (1998), approaches

that have attempted to find some elusive physiological or psychological

disorder, which could be construed as the cause of the pain, have generally

failed. The advantage of using an ecosystemic approach is that it does not

emphasize the origin of the subject's pain. All the subjects' complaints of pain

were, therefore, regarded as legitimate. The main emphasis, from an

ecosystemic perspective, lies in creating a context wherein a greater degree

10

of adaptation to pain may come about, regardless of the presumed underlying

pathology.

The success of ecosystemic hypnosis in this study was not decided by its

bringing about complete and permanent pain relief for the chronic low back

pain sufferer. As Spinhoven and Linssen (1989) state, a more realistic goal

when working with low back pain patients is a better adjustment to continuing

pain or learning to live with chronic pain, rather than curing pain or pain

reduction. Ultimately, the effectiveness and viability of any ecosystemically

oriented therapy for the chronic pain syndrome is determined solely in terms

of whether or not it has facilitated the development of more functional patterns

of interaction and relationships in the participant's ecology.

As stated, the focus of this study was to examine the use of hypnosis from an

alternative perspective. However, in order to do this, it is necessary to first

gain an understanding of hypnosis from the traditional paradigm. The

following chapter will first address hypnosis as viewed from a traditional

paradigm, before going on to examine hypnosis as viewed from an

ecosystemic perspective.

11

CHAPTER2

HYPNOSIS:

THEORETICAL BACKGROUND AND RESEARCH FINDINGS

2.1 Theoretical background

There are several theoretical explanations for hypnosis. These explanations

can be divided into two major categories, namely traditional, Newtonian,

positivist approaches and the new ecosystemic approach. This chapter will

provide a brief outline of these different approaches and look at how each

approach views the use of hypnosis for pain management.

2.1.1 Traditional Positivist Approaches

The traditional positivist approaches to be discussed are three broad

approaches, the state, non-state, and Ericksonian approaches, under which,

according to Fourie (1988), most of the traditional theories can be seen to be

subsumed.

State Approaches

According to Barber (1972) and Baker (1990), the traditional state or trance

paradigm is based on the following underlying assumptions:

• There exists a state of consciousness fundamentally different from the

waking and deep sleep state, which is referred to as hypnosis, trance, or

the hypnotic state.

12

• This "state" is usually induced by specific kinds of procedures called trance

inductions, although it may also occur spontaneously. All induction

procedures generally follow a similar format.

• A person in a hypnotic state remains so for a period of time, and is brought

out of it by a command from the hypnotist.

• In this hypnotic state the subject is responsive to suggestions which he/she

otherwise could not respond to, for example age regression, hallucination,

amnesia and suggested blindness.

• Different levels of depth of trance exist, ranging from light to

somnambulistic.

• The deeper the trance the more vivid and intense the subject's experience

of suggested phenomena.

Much of the state theorists' "proof' of an altered state of consciousness rests

on self-report and inferred experience.

How do the state approaches view pain management?

According to the state approaches the subject is able, through hypnosis, to

reach an altered state of consciousness. It is this altered state that is deemed

responsible for the subject's ability to deal with pain.

Prominent within the state approaches is Dissociation theory, which explains

the specific mechanism thought to be responsible for the analgesic effect of

hypnosis. According to Hilgard (1973), the historical roots of this view were

planted in psychoanalytic theory with concepts such as "conscious", "sub-

13

conscious", "unconscious", "id", "ego", "superego" and "subliminal self', all of

which divided the person into bits which were believed to be separate from

each other. Dissociation theory posits that once the subject is hypnotized, a

barrier is created which separates the cognition that feels pain, from the

cognition responsible for communicating this experience.

It is maintained that evidence in support of Dissociation theory can be found in

the fact that one may find physiological indications of pain in the subject, even

though the subject does not report pain. A study reported by Morse, Schoor

and Cohen (1984) evidences that Dissociation theory is accepted wisdom.

The authors state that the patient "usually was able to dissociate and take a

pleasant mental trip" (p.27).

Perry and Laurence (1983) provide a different view on pain management

within the state approaches. According to them, the success of hypnosis is

related to the manner in which the hypnotic induction interacts with different

degrees of hypnotic susceptibility or "receiver characteristics" (p.367). These

characteristics include imagery, absorption and dissociation and may vary in a

qualitative (different people have different combinations and permutations of

them) or in a quantitative manner (all people have different degrees of the

three characteristics). The implication is that hypnosis enables the subject to

tap into these characteristics through some kind of altered state. In addition,

the mechanics of the altered state of consciousness may be different for each

case.

14

Non-State Approaches

An alternative paradigm, which had its origins in social psychology and

behaviourist theories, was devised by the non-state theorists in response to

the supposedly "unscientific" methods employed by state theorists.

Proponents of the non-state theory limit research to observable behaviour

while ignoring more abstract inferences.

Non-state theorists reject the concept of an altered state of consciousness

and instead propose "role-taking" as a central concept. Sarbin and Slagle

(1972) speak of hypnosis as a special kind of social situation, and Spanos

(1991) maintains that hypnosis does not refer to a state or condition of the

person, but to role enactment.

Barber (1972) identifies the following basic assumptions of this paradigm:

• There is no fundamental difference in the state of a person who is in trance

and one who is not in trance.

• Both the person in trance and the one not in trance have attitudes,

motivations and expectations toward the communications or test

suggestions they are receiving.

• The person who is responsive to test suggestions has a positive attitude,

and the person who is unresponsive has a negative attitude.

• The three factors - attitudes, motivations and expectations - vary on a

continuum from negative to positive. These factors converge and interact

in complex ways to determine the subject's response.

15

• Concepts such as "trance", "somnambulism" and "dissociation" are

misleading and do not explain the overt and subjective responses.

• Responsiveness to test suggestions is a normal phenomenon that can be

conceptualised in terms of social psychology constructs.

• The phenomena associated with test suggestions are within the range of

normal human capabilities.

How do the non-state approaches view pain management?

Nicholas Spanos was one of the most important proponents of the non-state

approaches to hypnosis. According to his view, hypnosis is nothing more than

the use of socially-influenced cognitive skills and abilities. Spanos (1986,

p.449) explained hypnotic behaviour as "purposeful, goal-directed action that

can be understood in terms of how the subjects interpret their situation and

how they attempt to present themselves through their actions. . .. "good"

hypnotic subjects frequently behave as if they have lost control over their

behaviour . . . because their preconceptions about hypnosis and the

persuasive communications they receive in the hypnotic test situation define

acting that way as central to the role of being hypnotized."

Most of the work carried out by Spanos and his colleagues involved the

manipulation of the research situation or context, as well as experimenter

expectation cues, in order to show how hypnotic phenomena vary

accordingly. Spanos and Hewitt (1980) showed that they could manipulate

whether the "hypnotized" part of a subject felt pain as a result of different

hypnotic suggestions. Starn and Spanos (1980) demonstrated that the degree

16

to which hypnosis is effective in reducing pain is a function of preconceptions

regarding the efficacy of hypnotic analgesia as conveyed by the researcher to

the subjects.

Spanos and Radtke-Bodorik (1979) compared the cognitive strategies used to

control pain both by subjects under hypnosis and those not, and found no

differences. They thus concluded that the mechanism responsible for

hypnosis is not a mysterious automatic process. Rather, it is something the

subject is responsible for initiating and is nothing more than cognitive coping

strategies, such as distraction, imagining events inconsistent with the pain,

coping verbalizations and relaxation.

Ericksonian Approaches

Milton Erickson himself never formulated the theoretical basis of Ericksonian

hypnosis. His many followers have, however, explained his methods and

techniques in detail. For example, Haley (1973) takes an interactional view to

describe Erickson's method. Bandler and Grinder (1975) use a linguistic

approach based on transformational grammar to analyze Erickson's patterns

of communication. Rossi (Erickson, Rossi & Rossi, 1976; Erickson & Rossi,

1979), as a Jungian-oriented analyst, uses an intrapsychic perspective to

understand Erickson.

17

According to Fourie (1991 b), the following elements are basic to Ericksonian

thinking:

• A focus on individual, intrapsychic functioning

A central idea in Ericksonian work is that of a dichotomy between conscious

and unconscious functioning (Erickson, Rossi & Rossi, 1976; Gordon, 1985).

Havens (1985, p.55) states that Erickson believed that the unconscious was

an " ... observable, demonstrable, phenomenon ... people actually have an

unconscious mind . . . in the same sense that they have an arm or a leg"

(italics in original).

Ericksonians believe that the unconscious is a storehouse of resources and

untapped potential (Kirmayer, 1988; Lankton & Lankton, 1983). According to

Erickson, Rossi and Rossi (1976, p.18), "It is very important for people to

know their unconscious is smarter than they are. There is a greater wealth of

stored material in the unconscious."

In general, Ericksonian authors view hypnosis as the means by which

dissociation between the conscious and unconscious can be achieved

(Erickson & Rossi, 1979; Lankton & Lankton, 1983, 1986) and as a way to

activate unconscious processes (Ritterman, 1983). Once the resources

located in the unconscious are released into consciousness they can be

utilized to solve personal problems.

There is, therefore, in Ericksonian thought a focus on the individual and

his/her intrapsychic functioning.

18

• A focus on lineal cause and effect

The focus in Ericksonian hypnotherapy is on lineal, causal relationships and

the hypnotherapist is seen to exert a direct or lineal influence on the subject.

The hypnotic induction process is explained in terms of a lineal causal

relationship and the emphasis on technique also implies a lineal causal view.

• A focus on objectivity of observation

The Ericksonian approach places the therapist outside the client system. The

therapist is seen as being able to objectively decide which technique to use,

apply this technique from the outside, and objectively observe the effect.

• A focus on hypnosis as an entity

Most Ericksonian therapists are reductionistic in their view of hypnosis as an

entity. Erickson (1985) himself speaks of a state of special awareness and

Ritterman's (1983) idea that families hypnotize their members carries the

implication that a particular entity, which she calls "trance", is induced.

Hypnosis is thus perceived as an entity that exists in its own right. The

concept of hypnosis, used to describe certain behaviours, becomes reified,

and becomes an explanation for rather than a description of a particular class

of behaviours considered to be hypnotic.

How do Ericksonian approaches view pain management?

According to Fourie (1988) an Ericksonian approach explains the basis of

hypnosis as the only possible response to the special type of communication

19

leveled at the subject by the hypnotist. The emphasis in Ericksonian hypnosis

is on the perfection of techniques in order to obtain hypnosis. According to

Weiss (1993), Erickson described the following eleven basic hypnotic

procedures to be employed for pain control:

• Direct hypnotic suggestion for the total abolition of pain

• Permissive indirect hypnotic abolition of pain

• Amnesia

• Hypnotic analgesia

• Hypnotic anaesthesia

• Hypnotic replacement or substitution of sensations

• Hypnotic displacement of pain

• Hypnotic dissociation

• Hypnotic reinterpretation of the pain experience

• Hypnotic time distortion

• Hypnotic suggestions effecting a diminution of pain

Erickson specialized in the use of indirect techniques which, supposedly, by

pass consciousness, going straight to the unconscious- the site of hypnosis.

Ericksonian hypnosis also emphasizes the matching of subject variables or

characteristics to specific techniques.

Commonalities in the Traditional Approaches

Fourie (1988, p.143) states that the state, non-state, and Ericksonian

approaches all share two important elements, namely:

• They focus on the individual and his/her intrapsychic functioning

20

• They see hypnosis as being brought about or caused by an

induction/communication process.

2.1.2 The Ecosystemic Approach

The ecosystemic view of hypnosis is a departure from traditional approaches

to hypnosis, which locate hypnosis within the psyche of the subject and

largely ignore the context within which hypnosis occurs. Within an

ecosystemic framework it is assumed that phenomena cannot be understood

in isolation, but only in the context within which they manifest (Lifschitz &

Fourie, 1985).

Fourie and Lifschitz (1985, 1988, 1989) and Fourie (1988, 1995) delineate a

number of characteristics of ecosystemic hypnosis.

1. Hypnosis is a concept, not an entity

From an ecosystemic perspective, hypnosis is not viewed as an entity with its

own reality, but rather as a concept describing the behaviours which occur in

a particular context defined as hypnosis (Lifschitz & Fourie, 1985). Hypnosis

is thus a concept describing a situation in which certain classes of behaviour

are perceived as hypnotic or involuntary. Whether a particular class of

behaviour is perceived as hypnotic, or not, is determined by the opinions and

expectations held by those involved in the situation.

21

2. Hypnotic behaviours are designated as such by mutual qualification

Hypnotic behaviours are ordinary behaviours that are defined as hypnotic by a

process of mutual qualification. This process is based on the definition of the

situation as one of hypnosis, and on all the participants' ideas and

expectations regarding such a situation (Fourie, 1991 a). Any behaviour can

be mutually qualified as "hypnotic" provided that it fits with the expectations of

the people present. Fourie (1991 c) states that the process of mutual

qualification depends on the socio-cultural definition of the situation. He states

that the lifting of an arm in a classroom is likely to be interpreted and acted

upon quite differently from the same behaviour in a situation that is

designated as one of hypnosis.

3. The process of mutual qualification is an ongoing one

Fourie (1991a) states that the qualification of the first behaviour as "hypnotic"

is an evolutionary step in the developing of an ecology of ideas in the hypnotic

system. Subsequent to the initial qualification, the participants see that

hypnosis is happening, and may be more likely to view and qualify the

behaviours that follow as "hypnotic" as well. As each subsequent behaviour is

qualified as "hypnotic", the ecology of ideas strengthens around the view that

what is happening is hypnosis. According to Fourie (1991a) all participants

thus become increasingly convinced of the "reality" of hypnosis.

22

4. Hypnotic behaviours are not caused by anything

Ecosystemically seen, the hypnotist does not cause hypnosis. Instead he/she

organizes the development of a system in which hypnotic behaviours can

occur. This is achieved by means of an induction procedure. According to

Fourie (1991a) induction has the following two functions:

• It serves as a vehicle for the process of mutual qualification

• It punctuates the flow of events in such a way as to indicate that

behaviours during and subsequent to induction could be seen as and

qualified as "hypnotic"

Fourie (1988) states that the induction does not cause the hypnotic behaviour,

it merely helps to define the situation as a hypnotic one.

Chaves (1994, p.122) believes the following are essential elements of

hypnotic induction procedures:

• to create a series of experiences for the patient that help him/her to define

the situation as hypnotic

• to facilitate the focussing of attention and the engagement in goal-directed

imaginings

• to enhance the expectation that it will be possible to experience the clinical

benefits of participating in the hypnotic procedure

Chaves (1994) states that the induction procedure must have face validity for

the patient. In other words, the procedure needs to be seen as credible, within

the framework of the patient's expectation regarding hypnosis.

23

5. All participants in a situation defined as hypnosis have ideas and

attributions about hypnosis

Fourie (1991 c) states that these ideas and attributions play a role in the

process of mutual qualification. He states, for example, that onlookers seldom

speak to the subject or to the hypnotist when hypnosis takes place. There

seems to be a general idea that only the hypnotist should speak and then

usually only to the subject. The very silence of the observers, according to

Fourie (1991 c), helps to qualify the subject's behaviour as hypnotic as does

the fact that onlookers tend to pay attention to the subject, rather than to

somebody or something else.

With regard to expectations, Chaves (1994, pp.119-120) states that "virtually

all patients can be assumed to have expectations regarding the nature of

hypnosis, including impressions about how hypnosis is done, who is

responsive to it, what the typical outcomes are, and what dangers are

associated with hypnosis." According to Chaves (1994), patients will

sometimes have very specific expectations regarding such matters as how

they will be hypnotized or how they will achieve clinical gains.

Whereas other approaches to hypnosis hold certain client and family ideas

about as incorrect and often advocate the removal of such so-called

"misconceptions" prior to hypnosis (e.g. Yapko, 1995), the ecosystemic

therapist capitalizes on the expectations, attributions and conceptions the

client has regarding hypnosis. For example, if the client expects to lose

24

consciousness in hypnosis, the ecosystemic hypnotherapist can incorporate

this expectation into the therapeutic process.

6. There is no hypnotic susceptibility, only hypnotic responsiveness

When hypnosis is viewed from an ecosystemic perspective the concepts of

susceptibility or hypnotizability and depth, as embodied in Newtonian thinking,

need to be reconsidered. According to Chaves (1994), traditional approaches

to the use of hypnosis for pain management have generally emphasized the

need to select as candidates patients who are highly hypnotizable. Traditional

hypnotherapy approaches regard hypnotic susceptibility as some sort of

innate characteristic. Hawkins (1989) states that many therapists do,

however, maintain that under certain conditions all people are able to respond

to hypnosis. The Ericksonian school, for instance, maintains that the

hypnotizability scales only measure one type of hypnotic response (typically a

direct suggestion response) and that, while not everybody will respond to this

mode, they may well respond to more indirect hypnotic techniques, such as

the use of metaphors and hypnotic reframes. Hypnotic failures, according to

this view, are due "more to inflexible or inelegant therapists than to "resistant"

clients" (Hawkins, 1989, p.28).

The social context within which susceptibility testing takes place has been

consistently ignored. Such testing involves a highly structured setting. Fourie

and Lifschitz (1988) state that some subjects "fit" well into a structured testing

situation to the extent that they respond readily to the hypnotist's instructions.

These are the "highly hypnotizable" subjects referred to in hypnosis literature.

25

Other subjects do not "fit" as well with the situation and consequently score

lower on the scales. Sacerdote (1982, p.373) points out that the standardized

hypnotizability scales. are not comprehensive enough to tap all types of

hypnotic capacity and that it may even be unethical "to deprive even a small

minority of the potential help of hypnosis because of the negative impact of

low hypnotizability scores." Chaves (1994, p.119) states that "in general,

patients who are appropriate for any psychotherapeutic intervention are

potential candidates for hypnotic intervention".

The second concept that needs to be revised, from an ecosystemic

viewpoint, is that of hypnotic depth. Hypnotic depth is defined by Hilgard

(1981, p.25) as "a measure of the inferred hypnotic condition believed to

accompany hypnotic behavior on a particular occasion". Hypnotic depth is a

hypothetical construct inferred from the actual observed behaviour and should

not be construed to be an absolute reality.

Lifschitz and Fourie (1985, p.22) state that "the depth conception does not

contribute to a clear understanding of hypnosis". Fourie (1983) proposes that

the concept of "depth" be replaced by the "width of the hypnotic relationship".

According to him, the width of the hypnotic relationship refers to the range of

hypnotic behaviours that are possible within the scope of the hypnotic

relationship. The scope of the hypnotic relationship can be widened by means

of negotiation between all the parties present.

26

Ecosystemic hypnotherapy

An ecosystemic understanding of a problem opposes the traditional positivist

understanding of a problem as something that resides within the individual

and is caused in a linear way. The treatment of problems is not seen as lying

in the application of "cures" by an expert to the troubled individual.

Anderson and Goolishian (1988) explain that problems exist only in language.

Problems do not exist within a problematic component within a troubled

individual. A problem is only a problem to those languaging about it, or those

who share a consensual domain about the problem. Even while there is some

degree of shared understanding of the problem, each person involved in the

consensual domain, including the researcher, will have his or her own

linguistic reality of the problem. There may be consensus among some

members but rarely, if ever, among all. Thus, there is no single or correct view

of the problem, but rather multiple views constructed in language.

If problems are constructed in language, they must be solved through

language. However, because systems are self-reorganizing when it comes to

change (Boscolo, Cecchin, Hoffman, & Penn, 1987), the therapist cannot

predict the outcome of a particular intervention. According to Anderson and

Goolishian ( 1988) the most the therapist can do is enter the consensual

domain and perturb it in language until the problem changes and is open to

, alternative possibilities, or until it is no longer considered to be a problem.

27

The therapist's task is to interact with the members of the consensual domain

and their discrepant ideas so as to create a space for change. The therapist

must participate in having a dialogue that stimulates members of the

consensual domain to have new conversations with each other rather than

continuing to have the same conversation over and over again. The therapist

must help clients open themselves to others and accept their point of view as

being worthy of consideration. The skill of the therapist lies in maintaining the

continuance of the conversation until new meaning evolves.

From this explanation it becomes clear that the ecosystemic approach to

hypnosis would not involve applying hypnosis to a passive subject in order to

cure a problem. Instead, hypnosis is used as tool to perturb the consensual

domain or ideas about the problem. From an ecosystemic perspective it is,

therefore, important to discover the ideas in the system about hypnosis.

These are then incorporated into the hypnotic experience. It also becomes

important to conduct hypnotherapy, if possible, in the presence of all the

members of the consensual domain, as opposed to hypnosis merely being

conducted with the subject.

Fourie (1991 a) believes that the power of hypnotherapy lies in the power that

is attributed to it by the therapy system. Hypnosis is employed from an

ecosystemic perspective not because it possesses some intrinsic power, but

because clients and families believe that hypnosis is powerful (Fourie, 1991 a).

Since the client perceives hypnosis to be a potent technique, it acquires the

ability to perturb the client's ideas.

28

Each subject in the current study not only brings with him/her particular ideas

about hypnosis, but also about the problem of chronic pain. The participant's

ideas on chronic pain constantly evolve as the subject interacts with others

and with his/her environment. Once a client enters hypnotherapy, this system

of ideas becomes wider as the therapist's ideas about himself/herself, about

the client, about the problem etc. are introduced into the system. The

therapist's task will be to express ideas that link with those of the client, and

yet simultaneously change the client's ideas in a co-evolutionary way. Fourie

(1991 c, p.172) states that therapy should "provide to the client(s) a source of

ideas which are new to them, but not so different that they cannot understand

them".

How would an ecosystemic approach view pain management?

Griffiths, Griffiths and Slovik (1990) believe that chronic pain is often the

central theme in an ecology of ideas, or consensual domain, and that

intervention should be aimed at the level of ideas and meaning rather than

anywhere else. According to them attempts should be made to perturb the

ecology of ideas, through conversation, in a direction away from pain.

Fourie (1998) concurs that the focus should no longer be on the use of

hypnosis as an analgesic, but rather hypnosis should be utilised to facilitate

the co-construction of an ecology of ideas in which pain is not the central

theme any more. Fourie (1998) believes that hypnosis should be employed to

change the meanings around the pain and not to attack the pain itself and

29

thereby inadvertently give credence to these meanings. Fourie (1998) states

that treatment of the pain alone will be mostly unsuccessful because such

treatment, by focusing on the pain, confirms it in its central position.

2.2 Research findings

Besides the study by Basset, cited in the previous chapter, no studies

specifically employing ecosystemic hypnosis for chronic low back pain could

be found in the literature. Numerous others studies do, however, demonstrate

the efficacy of more traditional approaches to hypnosis for pain.

Chaves and Dworkin (1997) state that a 1995 NIH Technology Assessment

Conference Statement assessed the efficacy of hypnosis for clinical pain

control. It concluded that hypnosis has demonstrated efficacy for relief of

cancer pain and apparent usefulness for diverse conditions such as sleep

disturbance and the broad category of benign chronic pain, including back

pain.

According to Chaves and Dworkin (1997, p.368) "hypnosis seems to have an

admirable track record for facilitating symptom removal without yielding

subsequent symptom substitution." Chaves and Dworkin (1997) state that

there are many accounts of invasive surgical procedures performed with

hypnosis as the sole analgesic-anesthetic modality. Just as impressive to

Chaves and Dworkin (1997) are the many reports of successful postoperative

course following major surgery with hypnosis as the sole anesthetic. They

state that according to such anecdotal clinical accounts, minimal

30

postoperative pain medications seemed to be required, and healing seemed

uneventful, if not enhanced. Dworkin himself personally observed the

successes of using hypnosis as the sole anesthetic agent.

Bills (1993) reports the successful use of a multi-disciplinary approach,

including the use of hypnosis, in the management of a patient who had been

suffering chronic head, neck and back pain over a period of four years. The

patient had in those four years been seen by a number of different

practitioners, in various health-care fields, without a great deal of success.

Bills (1993, p.1) states that "hypnosis proved a flexible and useful treatment

instrument". He considers hypnosis to have been invaluable in helping the

patient learn to relax better and to develop a more positive attitude toward her

pain.

A key review article by Holroyd (1996) concluded that recent controlled

outcome studies comparing hypnosis to other psychological treatments for

chronic pain have shown hypnosis to be equally effective or more effective.

She notes that, despite clinical and experimental indications of the usefulness

of hypnosis for severe and persistent pain, and the fact that hypnosis is a safe

and non-invasive procedure, it is still not widely used. Among the studies cited

by Holroyd (1996), three recent ones in particular support the greater

effectiveness of hypnosis compared to other behaviour therapies. Firstly, the

1991 study by Haanen and colleagues which used hypnotic suggestions for

relaxation, improved sleep, and control of muscle pain with patients suffering

from fibromyalgia, a chronic condition with significant muscle pain and sleep

31

problems. The hypnosis intervention resulted in significantly greater

reductions of pain, sleep disturbance, fatigue and feeling sick, compared to

relaxation therapy plus massage treatment. Furthermore, 80% of the hypnosis

patients reduced their pain medication compared to only 35% of the

comparison treatment patients.

Secondly, Patterson, Everett, Burns and Marvin conducted a study in 1992

with burn patients. They used hypnotic suggestions for relaxation, analgesia,

amnesia and comfort when touched on the shoulder during debridement,

which is normally a very painful procedure. The hypnosis patients reported a

significant reduction in self-rated pain, whereas two control groups of patients

(pseudohypnosis and no treatment) did not.

Thirdly, Syrjala, Cummings and Donaldson conducted a controlled clinical trial

in 1992 to compare hypnosis to cognitive-behavioural training for the

reduction of pain and nausea during cancer treatment with 35 cancer patients

receiving bone marrow transplants. The cancer patients were randomly

assigned to one of four groups: hypnosis, cognitive-behavioural training,

therapist contact (attention-placebo control), or treatment as usual (no

treatment control). Patients in the hypnosis group had significantly and

consistently less pain from oral inflammation and ulceration due to marrow

transplantation than patients in the cognitive-behavioural training and

therapist contact groups. They also reported less pain even though they

tended to use less opioid medication.

32

Liossi and Hatira ( 1999) state that studies related to hypnotic treatment of

children who undergo bone marrow aspirations clearly demonstrate significant

reduction of pain and anxiety. Liossi and Hatira (1999) state that, compared

with various cognitive behavioural interventions, hypnosis is equally effective

in reducing self-reported pain in bone marrow aspirations.

Large (1995) provides a review of controlled studies using hypnosis for

chronic pain. A study conducted by Melzack and Perry in 1975 compared

alpha EEG-feedback with hypnosis, in the form of a modified Hartland ego

strengthening tape. Twenty-four patients with established chronic pain

syndrome were randomised to six patients receiving alpha-feedback, six

receiving hypnosis, and 12 the combination of both modalities. The

combination was the most effective condition in reducing pain, and hypnosis

was more powerful than alpha-feedback.

In 1980, Elton and colleagues compared behavioural psychotherapy with pill

placebo and hypnosis in 30 patients with chronic pain syndrome. The hypnotic

approach was individualised to patient needs. The hypnosis group had the

best outcomes.

A study by Whorwell in 1984 compared hypnosis, in the form of general

relaxation and ego-strengthening suggestion, with supportive psychotherapy

in 30 patients with irritable bowel syndrome. There were reductions in

subjective pain experience and abdominal distension with hypnosis, but not

with supportive psychotherapy.

33

Starn in 1984 compared the efficacy of hypnosis against that of relaxation

training in 61 patients with temporomandibular pain. Both treatment groups

improved compared with controls.

A study conducted by Olness in 1987 found that children with classic migraine

had a significant decline in headache frequency after learning self-hypnosis,

compared with propranolol or pill placebo. Large (1995) believes this is an

important study in that it compares a psychological treatment with an

"established" drug treatment in 28 children. Interestingly, the drug turned out

to be no better than the placebo.

In 1989, James conducted a multiple baseline study of 5 patients with chronic

pain syndrome who were classified as highly hypnotisable. Hypnosis was

individualised and each patient developed self-hypnosis exercises. Two

achieved long-term resolutions, two at the time of the writing of Large's article

continued to use self-hypnosis effectively, and one patient showed no change.

Prior in 1990 found that hypnosis reduced rectal sensitivity among diarrhoea

predominant patients in a group of 15 irritable bowel syndrome sufferers.

Large (1995) believes this study is significant in that it described a change in

an objective physiological measure as a consequence of hypnosis.

A study conducted by Van Dyck in 1991 randomised 55 patients with tension

headache to autogenic training or future oriented hypnotic imagery. The

34

treatments were equally effective. Finally, Spinhoven in 1992 compared

autogenics with self-hypnosis in 56 patients with tension headaches and

found that both groups improved.

The overall impression from these studies is that hypnosis is an effective

therapy in the management of chronic pain. The possibility that hypnosis,

undertaken from an ecosystemic perspective, could be equally or even more

effective is however, as yet, unexplored.

This chapter has outlined the various conceptualizations of hypnosis. The

following chapter will on go to examine the research design employed in the

current study.

35

CHAPTER3

RESEARCH DESIGN

3.1 A case study approach

This study made use of the case study approach. Yin (1993, p.31) states that

the major rationale for using this method is "when your investigation must

cover both a particular phenomenon and the context within which the

phenomenon is occurring, either because (a) the context is hypothesized to

contain important explanatory variables about the phenomenon or (b) the

boundaries between phenomenon and context are not clearly evident". The

case study method was, therefore, chosen because the researcher wanted to

cover contextual conditions - believing they might be highly pertinent to the

phenomenon of study.

Hamel (1993) states that the case study method is also the type of study best

suited to understanding the way in which the subject under investigation by

the researcher is defined or established through the set of meanings that

research participants will assign to their own experiences. The set of

meanings that participants assign to their experiences is central to an

ecosystemic approach. Spirer ( 1980) concurs that the direct contact of the

case study brings the researcher closer to the "real world" of the participants

and is the ideal approach to attempt to understand the situation as the

participants understand it.

36

The current study was an exploratory case study. The study attempted to

answer what Yin (1994, p.5) calls "what" questions, namely "What are the

effects of chronic pain on the participant and his/her family?" and "What are

the effects of ecosystemic hypnosis on chronic pain?" Yin (1994, p.5) believes

that "this type of question is a justifiable rationale for conducting an

exploratory study, the goal being to develop pertinent hypotheses and

propositions for further inquiry."

3.2 The sample

Purposive sampling and convenience selection was used in this study.

Participants were recruited through physiotherapists situated on the West

Rand and in Johannesburg. These areas were selected on the basis of

convenience in terms of the time and expense involved in travelling to and

from the different locations of those directly involved in the investigation. It

was also believed that the relatively large number of well-established

physiotherapy practices would yield an adequate number of participants

meeting the criteria for acceptance into the study. A letter outlining the nature

of the investigation and requesting the referral of suitable participants

(Appendix A) was mailed, or faxed, to each of twelve physiotherapists in

private practice. Follow up requests were undertaken telephonically in the two

instances where no response was obtained within 30 days of mailing or faxing

the original letter. The first batch of letters yielded five of the six participants

and the follow up requests yielded the sixth participant.

37

The following criteria were used when selecting participants:

• the participant must have experienced low back pain for six months or

longer

• the participant's back pain must not have responded to traditional and

conventional medical treatment, and the participant must not be in need of

further new surgical treatment

• the participant's pain must be qualified as interfering significantly with

his/her quality of life. (Because the experience of chronic pain is so

individual, this criterion was only loosely defined by the researcher and

was rated subjectively by each participant.)

• the participant and his/her family must give informed consent after the

treatment programme has been fully explained to them

A sample of six chronic low back pain patients was chosen for the current

study. The sample consisted of three married male participants and three

married female participants. Married participants were used because one of

the aims of the study was to describe the impact of chronic low back pain on

the family system. Male and female participants were included so that

possible sex differences in the subject's, and the family's, experience of

chronic low back pain could be noted. For example, Roy (1989) found that,

with regard to affective roles, children are more affected by pain problems in

their fathers than in their mothers.

Initial contact was made with the prospective participants by telephone. The

nature of the investigation was briefly explained and it was verified that the

38

participant met the research criteria. The participants were informed at this

stage that it was not possible to stipulate from the outset how many sessions

would be employed and that the researcher could not guarantee that any

benefits (in terms of permanent pain relief or otherwise) would be derived

from their participation in the study.

A letter of consent was mailed or faxed to each research participant and each

was asked to sign the letter prior to the first interview with the author (See

Appendix B). The letter briefly outlined the aims of the research project and

the nature of the individual's participation. Participants were informed that the

researcher was interested in finding out what effect their pain has on their

day-to-day functioning, as well as on their relationships. Participants were

also informed that hypnosis would be employed as a treatment modality.

Participants were informed during the initial telephone call, and in the letter of

consent, that they were free to withdraw from the investigation at any time

should they wish to do so. The letter also contained the assurance that all

information supplied by the participant would remain confidential and would

not be communicated to anyone not directly connected with the study.

3.3 Variables

Pain must be present for six months or longer to for it to be defined as

chronic. In this study, chronic low back pain functioned as an independent and

dependent variable. The effects of chronic pain (as an independent variable)

on the family system (as dependent variable) are described. The effects of the

39

independent variable hypnosis, as viewed from an ecosystemic perspective,

on chronic pain (as dependent variable) are also detailed.

In research conducted from an ecosystemic viewpoint all variables are, as far

as possible, accounted for and no variables are considered to be "nuisance"

variables. As McCaslin (in Spirer, 1980) states, one of the benefits of

naturalistic inquiry (which subsumes the case study approach) is that it allows

recognition of the multiplicity of causes that may lead to a certain outcome

and recognizes that causes and outcomes can interact in a variety of ways.

Naturalistic inquiry is not constrained to examining only those outcomes

amenable to quantification and allows the researcher to collect information on

outcomes not known to be important or anticipated during the design of the

study. Therefore, an attempt is made to account for all variables in the final

analysis.

3.4 Measuring Instruments

A. The McMaster Model of Family Functioning

The McMaster Model of Family Functioning (MMFF) was used to assess and

describe the consequences of chronic low back pain on various aspects of the

functioning of each sufferer's family. Such a description was deemed

necessary because, as Barber (1986, p.165) states, "the particular way an

individual patient's pain is integrated into his or her life will determine some of

the twists and turns that treatment is likely to take."

40

Although some may consider the MMFF relatively old, it does still have its

advantages. According to Epstein et al. ( 1982, p.139) the usefulness of the

MMFF lies in the richness of description that the model provides and the fact

that the model was developed through a process of clinical and empirical

testing. In developing the MMFF, aspects of family functioning were

conceptualized and then tested in clinical work, research and teaching.

Problems arising in applying the model became the basis for reformulation.

Epstein et al. (1982, p.117) believe that "the result is a pragmatic model

containing ideas that have worked" as those ideas not meeting the test in

treatment, teaching or research have been discarded or modified.

Roy ( 1985a, p.303) states that, given the substantial changes that families

with a chronic pain patient undergo, "it is quite imperative to assess the family

functioning on multiple dimensions." Roy (1985a) believes the dimensions of

family functioning described by Epstein and his colleagues serve that purpose

well. Using the MMFF for the present study was advantageous in that the

MMFF has proved capable of assessing the impact of an event (such as

illness in a family member) on the overall functioning of the family.

The MMFF allows the family's structure, organization and transactional

patterns to be detailed, and all the problems that currently exist are

elucidated. Epstein and Bishop (1981) believe that that the MMFF allows the

researcher or therapist to focus on the specific problems of the specific family.

41

According to Epstein et al. (1982) the concepts contained in the MMFF have

evolved from studies of normal as well as clinical populations and, as a result,

they define health as well as pathology. Therefore, the MMFF helps the

therapist and family members become aware of their strengths and not only

their shortcomings.

The MMFF is based on a systems approach. Epstein et al. (1982) state that

the crucial assumptions of systems theory that underlie their model are:

• The parts of the family are interrelated.

• One part of the family cannot be understood in isolation from the rest of the

system.

• Family functioning cannot be fully understood by simply understanding

each of the parts.

• A family's structure and organization are important factors determining the

behaviour of family members.

• Transactional patterns of the family system shape the behaviour of family

members.

Epstein et al. (1982) state that the MMFF does not cover all aspects of family

functioning, but focuses on the dimensions of functioning that are seen as

having the most impact on the emotional and physical health problems of

family members. The six areas of focus in the MMFF are problem solving,

roles, communication, affective responsiveness, affective involvement and

behaviour control. According to Epstein and Bishop (1981) the MMFF does

not focus on any one of the dimensions as the foundation for conceptualizing

42

family behaviour. Epstein and Bishop (1981, p.448) believe that many

dimensions need to be assessed for a fuller understanding of "such a complex

entity as the family".

1. Problem Solving

Epstein et al. (1982) define problem solving as the family's ability to resolve

problems to a level that maintains effective functioning. Family problems are

divided into two types, namely instrumental and affective. Instrumental

problems relate to issues that are mechanical in nature, such as the provision

of money, food and so on. Affective problems relate to issues of emotion or

feeling, such as depression or anger.

Epstein et al. (1982) describe effective problem solving as a sequence of

seven steps:

1. Identifying the problem

' . 2. Communication with appropriate people about the problem

3. Developing a set of possible alternative solutions

4. Deciding on one of the alternatives

5. Carrying out the action required by the alternative

6. Monitoring the action

7. Evaluation of success

According to Roy (1989), clinical experience suggests that a family with a

chronic pain patient is likely to encounter considerable difficulty in the domain

of problem solving, particularly in the affective area. Roy (1989) states that

.these families are rarely able to go beyond the first stage of the problem

43

solving process, namely, problem identification. Such families are also likely

to blame their problems on pain, rather than on relationship problems. Roy

(1989) believes effective problem solving is also affected in varying ways, and

to varying degrees, by the degree of investment that patients and family

members have in maintaining pain behaviours, the duration of the pain

problem, the degree of disability of the pain sufferer, and life-stage issues.

2. Communication

Communication is defined as how information is exchanged within a family

and the focus is on verbal exchange. Communication is also divided into

instrumental and affective areas. In addition, Epstein and Bishop (1980)

identify two other dimensions of communication: clear versus masked and

direct versus indirect. The former focuses on the clarity with which the content

of the information is exchanged. The latter considers whether the message

goes to the person for whom it is intended.

The two above-mentioned dimensions yield four styles of communication: (a)

clear and direct (b) clear and indirect (c) masked and direct and (d) masked

and indirect. The model postulates that the more masked and indirect the

overall family communication pattern is, the more ineffective the family's

functioning; the more clear and direct the communication, the greater its

effectiveness.

Communication problems are common in a family with a chronic pain sufferer.

Roy (1989) states that families who generally engage in clear and direct

44

communication may find themselves altering that pattern. Spouses may find it

difficult to express their feelings when their partner is ill-tempered, distant and

unapproachable. Even when communication is direct and clear, especially by

the well partner, it may result in reinforcement of pain behaviours.

3. Roles

Epstein and Bishop (1980, p.460) define family roles as "the recurrent

patterns of behaviour by which individuals fulfill family functions". The MMFF

divides family functions into instrumental and affective areas. Instrumental

refers to the provision of resources. The affective area relates to nurturance,

support, sexual gratification of marital partners and other affective domains of

interpersonal relationships (Roy, 1989).

Chronic illness in one member of the family has profound implications for role

functioning for other family members. The occupational roles of back-pain

sufferers are often severely compromised. Roy (1989) conducted a study with

headache and backache sufferers and found that out of the eight

breadwinners in the back pain group, seven were unemployed at the time of

the study. Job loss creates financial hardship for the family, and the burden of

responsibility to provide financially can fall on the spouse. Job loss also leads

to a loss of self-esteem for the individual sufferer. An inability on the part of

the chronic pain patient to carry out simple chores can lead to the spouse

having to assume additional responsibilities for running the household as well.

45

Chronic pain often has a negative impact on the performance of tasks

associated with nurturance and support. Roy (1989) states that marital

partners may have a sense of disengagement from each other and there is

often a measurable deterioration in the quality of their sexual relationship.

According to Roy (1989), with regard to affective roles, children are more

directly affected by pain problems in their fathers than in their mothers. One

plausible explanation offered by Roy (1989) is that mothers go to

extraordinary lengths to maintain their nurturing and supportive roles in

relation to the children.

Roy (1985b) states that because spouses frequently adopt a highly protective

attitude they may prevent the patients from fulfilling roles that they

conceivably can undertake. On the other hand, according to Roy (1985b),

pain may be used to stop performance of those roles and functions that the

patient has always found hard or distasteful.

4. Affective responsiveness

Affective responsiveness deals with the actual experience of feelings. In other

words, it does not deal with the expression of emotions, but with what one

feels. A family should be able to respond to a range of stimuli with the

appropriate quality and quantity of feelings.

As an aid to assessment, responses are divided into two classes: welfare

feelings and emergency feelings. Welfare feelings are exemplified by positive

46

emotions such as love, tenderness, happiness and joy; emergency feelings by

fear, anger, sadness, depression, and disappointment.

Emotional reactions to illness are many and varied. Roy (1989) states that a

common observation is that the spouse of the chronic pain patient, as well as

the children, often withholds much of his/her anger and sadness. Roy (1989)

finds that comments such as "How can you be angry with somebody who is in

pain?" are common.

Roy (1989) believes that chronic pain patients experience a multitude of

negative or emergency emotions. Sometimes these emotions are expressed,

or, at other times, the only manifestations of such feelings are social

withdrawal or even more preoccupation with pain. Roy (1989) states that

welfare emotions are neither felt nor expressed and that the prevailing

emotional climate within such families is largely determined by emergency

emotions.

5. Affective involvement

Affective involvement is concerned with the degree to which family members

care for one another, show interest in and value the activities and interests of

individual family members. Six types of affective involvement are identified:

1. Lack of involvement

2. Involvement devoid of feeling

3. Narcissistic involvement

4. Empathic involvement

47

5. Over-involvement

6. Symbiotic involvement

Empathic involvement is viewed as the most effective form of affective

involvement. Involvement devoid of feelings, narcissistic, or over-involvement

is considered less effective. Lack or involvement or symbiotic involvement is

viewed as the least effective.

Roy (1989) states that a rather common pattern between the spouse and the

chronic pain sufferer appears to be a mixture of over-involvement and lack of

involvement. Patients typically engage in withdrawal from their normal social

intercourse and other role-related behaviours, whereas the spouse becomes

over-solicitous and anxious to please.

Roy (1984) believes that the affective involvement of the chronic pain sufferer

may vary depending on how much pain the person has on a given day.

6. Behaviour control

Epstein and Bishop (1981) define behaviour control as the pattern a family

adopts for handling behaviour in three types of situations, namely: (1)

physically dangerous situations (2) situations which involve meeting and

expressing psychobiological needs or drives and (3) situations involving

interpersonal socializing behaviour.

48

The behaviour of all family members in each type of situation is considered.

When assessing the appropriateness of the rules and standards of the family,

the age and status of the individuals concerned are taken into account.

Families develop their own standards of acceptable behaviour, as well as the

degrees of latitude that they will permit in relation to these standards. The

nature of these standards and the amount of latitude for acceptable behavior

determine the four styles of behavioural control: rigid, flexible, laissez-faire

and chaotic.

In situations of rigid behaviour control, family standards are very inflexible and

there is little or no room for negotiation and change regarding family rules.

Flexible behaviour control entails a flexibility of rules necessitated by specific

situations. Laissez-faire behaviour control entails an "anything goes"

approach: firm standards do not exist and extreme permissiveness is the rule.

In chaotic behaviour control there is no consistent style: rules come and go

without obvious reason, and there is much shifting from one kind of behaviour

control to another.

Epstein and Bishop (1981) believe that flexible behaviour control is the most

effective. They list the remaining styles in decreasing order of effectiveness as

rigid, laissez-faire and chaotic.

According to Roy (1984), the presence of a chronically sick person within a

family system is likely to result in an alteration of rules and mechanisms of

behaviour control. He states that, for less well-functioning families, problems

49

surrounding the issues of rules are frequently self-evident. Such problems

could range from rigid and inflexible rules to a virtual absence of rules. In a

study of 20 chronic headache patients and their spouses, conducted by Roy

in 1987, he found that 16 of the couples engaged in unhealthy forms of

behaviour control. According to him, the rules in these families changed

directly as a consequence of significant role alterations. Roy's conclusion was

that the presence of a chronically sick person within a family system was

more than likely to result in alteration of rules and mechanisms of behaviour

control. In a subsequent study in 1987, Roy found that 93% of the back pain

and 80% of the head-pain couples engaged in unhealthy behaviour controls,

which ranged from rigid to chaotic. Therefore, only seven percent of the back

pain and twenty percent of the headache couples gave evidence of flexible, or

healthy, types of behaviour control.

A key question during the assessment is what purpose the pain serves, either

for the patient, or for the family. For example, Roy (1986) states that chronic

pain in the spouse may relieve the partner of sexual and other marital

responsibilities, and the pain may be used to discourage the patient from

making demands felt to be unacceptable to the partner. In addition, the

healthy spouse may encourage the patient's position of dependency, thus

reinforcing the pain behaviour to his or her own end. The perpetuation of

chronic pain may also be attributed to personal factors, either as a way of

seeking attention, or of avoiding responsibilities, by the chronic pain sufferer.

Family members frequently treat this person as an invalid and expect less and

50

less from him or her. This then decidedly sets the scene for perpetuation of

the problem.

Unraveling the meanings of pain that patients and family members attribute to

the symptom is also of the utmost importance. Roy (1985b) states that the

attribution of meaning to pain by the patient and the spouse is likely to be

extremely varied. Rowat and Knafl (1985) conducted a study into the spouse's

understanding of his/her mate's pain. Thirty eight percent of the spouses

stated that they could not describe their mate's pain and sixty percent of the

spouses admitted they found it difficult to understand their mate's pain. Rowat

and Knafl (1985, p.262) state that a typical comment was: "I've never heard of

people having pain such that there's no apparent cure ... people that have

pains that can't be explained".

B. The Brief Pain Inventory

The Brief Pain Inventory (BPI; see Appendix C) is a brief and easy to use tool

for the assessment of pain in both clinical and research settings. Charles

Cleeland, who is currently the director of the Pain Research Group at the M.D.

Anderson Cancer Centre, is the original author of the inventory. The BPI is

based on the idea that pain consists of two dimensions, namely a sensory and

a reactive dimension (Cieeland, 1989). The BPI was, therefore, developed to

separately measure both pain severity (the "sensory" dimension) and how

pain interferes with the patient's function and quality of life (the "reactive"

dimension).

51

The BPI is a two-page questionnaire and requires approximately five minutes

to complete. Comparable information is obtained by self -administration and

by interviewer administration (Cieeland, 1995). The inventory asks patients to

rate their pain for the last week on zero to ten numerical rating scales

presented as a row of equidistant numbers. The use of eleven point rating

scales maximizes a trade-off between subject ease of responding and

increasing reliability with longer scales (Nunnally, 1978).

With regard to severity of pain, the BPI asks patients to use the zero to ten

rating scales to rate the severity of their pain at its (a) "worst", (b) "least", (c)

"average" and (d) at the time the rating is made - (e) "now". Each scale for

Worst Pain, Least Pain, Pain on the Average, and Pain Right Now is bounded

by 0 = no pain and 10 = pain as bad as you can imagine.

Items for the BPI's interference scale were selected so as to tap how pain

impairs both level of function (e.g. walking) and social affective well-being

(e.g. mood). Using the same type of scales, patients are asked to separately

rate how their pain interferes with their Enjoyment of Life, Activity, Walking,

Mood, Sleep, Work, and Relations with Others. These scales are bounded by

0 = does not interfere and 10 = interferes completely.

The BPI was first developed in English, but has been validated in several

languages and has become established as a standardized instrument for

multinational studies (Radbruch, Loick, Kiencke, Lindena, Sabatowski, Grand,

Lehmann & Cleeland, 1999). Unfortunately, the BPI has not yet been

52

translated into any of South Africa's other 10 official languages, although

validation studies for an Afrikaans, a Sepedi, a Tswana, a Xhosa and a Zulu

version of the inventory will soon be undertaken by the Pain Research Group.

The English version of the BPI was, therefore, used for this particular study.

Although not all respondents were English first language speakers, the BPI's

simple format and its focus on a limited number of relatively universal

functions did still justify its use.

Cronbach alpha reliability ranges from . 77 to .91 for the BPI. It was anticipated

that a number of the participants in the current study would be bilingual.

Saxena, Mendoza, Cleeland (1999) conducted a project that developed and

validated a Hindi version of the BPI using a sample of bilingual (Hindi and

English) patients. This study found alphas of 0.90 for both the interference

and severity subscales of the English BPI when used with the bilingual

(English/Hindi) group.

Construct validity of the BPI has been confirmed by factor analysis. Factor

analysis of the original version of the BPI showed two factors. The pain

intensity ratings load high on a common factor (pain severity) while the seven

interference items showed high loadings on another factor (interference with

function). Validation of the BPI in different languages consistently

demonstrates these two common factors (Radbruch et al., 1999). Evidence of

construct validity for the BPI was also provided by statistically significant chi

square analyses between patients' pain ratings and opioid and non-opioid

medication (Daut, Cleeland & Flanery, 1983).

53

The BPI has, according to Cleeland and Syrjala (1992), proved useful for pain

monitoring and was, therefore, used in the current study to help keep track of

treatment progress. The BPI does not need complicated procedures for

evaluation (Radbruch et al., 1999). With regard to the pain severity items, for

analysis the pain worst item can be chosen as the primary response variable,

with the other items serving as a check on variability. In a study by Serlin,

Mendoza, Nakamura, Edwards and Cleeland (1995) it was found that pain

worst scores of 1-4 correspond to what might be thought of as mild pain,

scores of 5-6 as moderate pain (or significant pain) and scores of 7 or greater

as severe pain, based on the level of interference with function reported by

patients. Alternatively the pain severity items can be combined to give a

composite index of pain severity (Wang, Mendoza, Gao & Cleeland, 1996).

The current study employed the pain worst item as the primary response

variable.

With regard to the seven pain interference items the mean of these scores

can be used as a pain interference score, as was done in the present study.

Permission was obtained from Dr Cleeland to use the inventory for the current

study. Dr Cleeland also confirmed that the purpose of the study is congruent

with the intended use of the BPI.

54

3.5 Method

All sessions were conducted in the participants' respective homes. The

reason for this was to attempt to let the participants feel as at ease as

possible, and also to allow the researcher to observe the family in their own

environment. Weekly sessions were conducted with participants. It was hoped

that this would convey to participants that the researcher viewed their pain

problem seriously enough to warrant an intensive approach to treatment.

The first session and part of the second session were used for assessment of

the family's functioning, using the McMaster model of family functioning.

When seeing the family for the assessment the aim was to have present all

the family members living at home. This allowed the researcher to obtain a full

range of views. Knowledgeable children were asked to wait in another room,

when assessing the parent's sexual relationship.

Whether all family members or any family members were asked to attend

subsequent sessions after the initial assessment, was decided on a case-by

case basis.

The second session was also used to assess the participant and, if

necessary, his/her family's expectations regarding hypnosis as a form of

treatment. The chronic low back pain sufferer also completed the Brief Pain

Inventory in the second session.

55

Hypnosis was employed from the third session on. No fixed number of

sessions was set; the number of sessions was decided on a case-by-case

basis.

From an ecosystemic perspective, the techniques to be employed depended

on each participant's (and family's) expectations and were, therefore, different

for every participant. The following ways in which the ecology of ideas could

possibly be perturbed were considered in the research design phase: the use

of metaphor, reframing, relaxation, externalization, sensory substitution and

displacement.

Using metaphor is a creative way of introducing new ideas into a system. In

ecosystemic terms, a metaphor is not perceived as having a lineal effect on a

client. Instead it is seen as a perturbation of an existing set of ideas.

According to Fourie (1991 c) different clients will attribute different meanings

to, and respond differently to, the same metaphor, based on their own ideas

and on the ecology of ideas existing in the therapeutic system at the time. He

states that the more complicated the metaphor, the more there is for them to

think about and the wider the range of possible actions for them to take.

Reframing can perturb the way the client system thinks about the problem and

help the client understand his/her behavior in a different way. Watzlawick,

Weakland and Fisch (1974) define reframing as a change of the client's

definition of reality. Watzlawick et al. (1974, p.95) state that to reframe means

"to change the conceptual and/or emotional setting or viewpoint in relation to

56

which a situation is experienced and to place it in another frame which fits the

"facts" of the same concrete situation equally well or even better, and thereby

changes its entire meaning." According to them a change may take place

while the situation itself may remain quite unchanged and, indeed, even

unchangeable. They state that what turns out to be changed as a result of

reframing is the meaning attributed to the situation, and therefore its

consequences, but not its concrete facts.

Watzlawick believes reframing works because once we have perceived the

new "reality" we cannot so easily go back to "the trap and anguish of a former

view of "reality". Watzlawick (1974, p.103) states, however, that not just any

other frame will do, but only one "that is congenial to the person's way of

thinking and of categorizing reality". Successful reframing, therefore, needs to

take into account the views, expectations, reasons, and premises of those

whose problems are to be changed."

Relaxation is not considered, from an ecosystemic perspective, to be a

necessary outflow of hypnosis. However, because many clients believe

hypnosis to be a powerful relaxation tool, this association can be used

therapeutically. Simple relaxation techniques may be defined as "self

hypnosis" techniques. Relaxation techniques are commonly used for chronic

pain and, according to Tunks (1982, p.191 ), can improve the patient's sense

of mastery and reduce the sense that stress is overwhelming.

57

Michael White and David Epston (1990, p.38) state that externalizing is "an

approach to therapy that encourages persons to objectify and, at times, to

personify the problems they are experiencing as oppressive". The problem is

made a separate entity, external to the person or the relationship to which it

was originally ascribed. White and Epston (1990, p.38) state "those problems

that are considered to be inherent, as well as those relatively fixed qualities

that are attributed to persons and relationships, are rendered less fixed and

less restricting."

White first used this approach within the context of work with families that

presented for therapy with problems identifies in children. White (1990, pp.38-

39) believes that externalization, among other things:

• Decreases unproductive conflict between persons, including those

disputes over who is responsible for the problem

• Undermines the sense of failure that has developed for many persons in

response to the continuing existence of the problem despite their attempts

to resolve it

• Paves the way for persons to cooperate with each other, to unite in a

struggle against the problem, and to escape its influence in their lives and

relationships

• Opens up new possibilities for persons to take action to retrieve their lives

and relationships from the problem and its influence

• Frees persons to take a lighter, more effective, and less stressed approach

to "deadly serious" problems, and

• Presents options for dialogue, rather than monologue about the problem

58

Sensory substitution and displacement can also be used to help the patient

experience a change in the perception of pain (Barber, 1986). In sensory

substitution suggestions can be used to create a reinterpretation of

sensations. A sensation of intolerable burning can, for example, be replaced

by a sensation of coldness. The substituted sensation need not, according to

Barber (1986), be a pleasant one. Barber (1986, p.157) states that such a

substitute feeling has several virtues: (a) It allows the patient to know the pain

is still there; (b) it is not particularly pleasant, so it is more plausible than, say,

a sensation of pleasure; and (c) if one is still feeling uncomfortable- but not in

agony __, many secondary gains associated with pain can still be obtained

without suffering. Barber (1986) believes that suggestions for sensory

substitution are most effective if they incorporate the qualities of the patient's

personal experience of pain, and suggest a plausible modification of quality.

Displacement of the pain involves moving the pain from one area of the body

to another, or sometimes to an area outside of the body (Barber, 1990). The

effectiveness of such suggestions, according to Barber (1986), can be

increased if the patient is allowed to choose the direction or location of

movement. The primary goal is to change the locus of pain experience so that

the pain is less disabling or threatening, but, as Barber (1986, p.157) states,

an important implication of such modification is that if pain can change in

location, then it may also be changeable in other dimensions.

59

Each participant completed the short form of the Brief Pain Inventory on a

weekly basis at the end of each hypnosis session. The decision of the

appropriate time to terminate treatment was made on a case-by-case basis.

3.6 Validity

Qualitative research differs fundamentally from conventional quantitative

research in its conceptions of knowledge, truth, and objectivity. Quantitative

methods insist on unequivocal knowledge based on the assumption that

reality can be discovered (Fourie, 1996). To obtain an accurate map of

"reality", stringent efforts are made to remove every aspect of subjectivity and

researcher bias from the inquiry, since it is believed they will contaminate the

data. Moreover, to be able to arrive at an unequivocal outcome reflecting the

"truth" the complexities of social relationships and contextual factors must be

eliminated or controlled for as far as possible (Fourie, 1996).

In recent times, psychologists have begun to question the applicability of

Newtonian research criteria to psychological phenomena. According to

Lincoln and Guba (1985, p.114) "it is difficult to imagine a human activity that

is context-free". Moon, Dillon and Sprenkle (1990) state that a qualitative

research paradigm could be regarded as more suitable for investigating social

science phenomena since it relies on the research participants' perspectives

to make sense of complex situations and interactions. Since meaning is

contextual, not atomistic, qualitative research explores the complex

interrelationships amongst events in their meaning creating natural settings

(Moon et al., 1990). Qualitative research does not subscribe to the notion of

60

"objectivity". Instead it is assumed that any social phenomenon can be

described "accurately" from many viewpoints and that any point of view can

only be partial (Lincoln & Guba, 1985).

The question of legitimacy in positivist research is dealt with in terms of strict

criteria of internal and external validity and much attention is paid to scientific

methods which guarantee as far as possible the validity of findings (Reason &

Rowan, 1981). In qualitative research however, the assumptions of

generalizability and absolute knowledge are no longer primary. Because the

basic assumptions are different, the issues of validity and legitimization

change. Numerous ways of achieving research legitimacy for qualitative

research do exist. Those that are relevant to this study will be discussed

below.

Moon, Dillon and Sprenkle (1990) state that since the researcher is the

primary data collection instrument in most qualitative studies it is important to

make the researcher role clear and to make known any researcher biases.

In the current study the researcher is a chronic pain sufferer.

Atkinson and Heath ( 1987) believe the presentation of findings in quantitative

studies is actually limited because the data is presented only after having

been organized and categorized. Thus, the reader is given no opportunity to

question the researcher's construction and has to concur with the

researcher's validity appraisals. The alternative they offer is for the researcher

to provide as much true raw data as possible, so that the reader can

61

determine issues of legitimacy. This study, therefore, needs to provide as

much information as possible in the form of rich, detailed descriptions. Each

case will be described in full and then a metaperspective will be given which

will concentrate on explaining the therapeutic rationale. Lincoln and Guba

(1985) state that by presenting a vivid, lifelike description and allowing

readers to achieve a personal understanding through their own tacit

knowledge, the case study does permit an assessment of transferability.

3. 7 Analysis of data

According to Spirer (1980), the analysis of case study data is an ongoing

process, which begins as soon as the first piece of datum is collected. This

feature of "analyze as you go" distinguishes the case study from other

methodologies in which the data collection and data analysis are discrete

activities.

Bogdan (1972, p.58) states that "as the researcher is in the field and

recording his notes, he then begins focussing on certain recurrent themes,

which are revealed in observed behaviour and verbalisation". Certain

understandings will begin to develop, inferences will be drawn, new questions

will be raised, and themes will develop that will adjust the scope, focus and

schedule of the treatment sessions accordingly and determine where the

researcher will spend her time.

62

3.8 Possible problems

A number of possible problems with the present study were identified in the

research design stage. Firstly, the possibility that the chronic pain sufferer

would be unwilling to see the need for a psychological solution. Roy (1989)

states that, for the chronic pain patient, the idea of having a disease is a

source of some hope, in that a disease can be cured. According to Roy

(1989), reassurance that a disease has not been found - which would

normally be a cause for celebration and relief for most people - often

becomes a source of great frustration for chronic pain sufferers.

Roy (1989) conducted a study with 32 headache and backache patients,

using problem-centered family systems therapy. He states that the backache

patients tended to be essentially healthy individuals whose problems

commenced with a specific event such as a trauma or accident. According to

Roy, the backache sufferers in particular were less inclined to accept that their

pain problem could be linked to underlying psychological factors. He believes

that by defining these patients' pain problems in psychological terms they may

feel their problem is somehow being trivialised and not believed. The

therapist, therefore, needs to convey to the patient that they are confronted

with serious difficulties in their lives due to the chronic nature of their pain

problem, that no one in the family is unaffected by it, and that the goal is to

help the family function more effectively.

63

Problems were also anticipated with getting the whole family to attend the

assessment and, if necessary, subsequent sessions. Roy (1989) notes that all

32 patients in his study were asked to bring their spouses to the first meeting.

None did. Most stated that it was their pain; they were the patients and did not

see the need to involve their partners and other family members. Roy (1989)

does state, however, that after the first session patients lost their fear and

reluctance to involve their family members.

Problems were specifically anticipated in the current study with relation to

getting the spouse of the chronic pain sufferer to attend. Waring (1982)

suggests a number of measures to obtain the spouse's co-operation. He tells

the spouse that, in his experience, all spouses suffer with the chronic pain of

the identified patient and that discussion of the suffering may lead to specific

interventions which can improve the patient's clinical condition. Waring (1982)

also believes that the initial marital assessment must be a positive experience

for both spouses if you realistically expect to have the opportunity to see them

both again. He states that the spouse must be able to vent the depression,

feelings of helplessness and hopelessness, and anger that are invariably

present. He also allows time for the spouse to express his/her feelings,

thoughts and expectations about being called in for a joint interview. Waring

(1982) finds the spouses' response, far from being a hostile one, is actually

one of relief that they have finally been brought into the treatment program.

Problems were also anticipated with regard to the use of hypnotherapy. Evans

( 1991) states that the typical chronic pain patient will generally have

64

unsuccessfully attempted several treatment approaches before coming to the

hypnotherapist. These will often have included various neurological

procedures, manipulative procedures by orthopaedists and chiropractors, and

medication. The typical chronic pain patient will simultaneously take many

different medications. For many of these patients, the demand, "Hypnotise me

and get rid of my pain" is, according to Evans (1991), an invitation to failure.

The burden of cure is abrogated to the magic of the technique rather than the

patient's taking an active role in his/her treatment.

The following chapter will describe the six case studies in detail, allowing the

reader as much contact as possible with what unfolded in each case and

allowing the reader to draw distinctions of his or her own. At the end of each

case study a metaperspective will be given to allow an understanding of the

role of the author as researcher and therapist and an understanding of the

process of each case.

65

CHAPTER4

REASEARCH RESULTS

This chapter will provide a detailed, narrative description of the six cases

undertaken for the study. In this instance, the term "narrative" is taken to

mean "communicated meaning" (Fourie, 1995, p.304) and as such, is

explicated from a subjective or "participant observer" (Moon et al., 1990,

p/360) point of view. The description will be in such a manner as to draw

attention to the ecosystemic rationale behind each case. For this purpose,

each case will be described in detail and then a metaperspective will be given.

While the metaperspectives will concentrate on explaining the therapeutic

rationale, the case study descriptions will be detailed enough to give the

reader a feel for the characteristics of ecosystemic hypnosis described

previously.

In accordance with ethical considerations of confidentiality, the names of the

participants have been changed.

4.1 MANDY

Mandy was referred by her physiotherapist, but it was her husband, Dylan,

who made contact before the referral could even be followed up. Mandy had

been suffering from low back pain for a total of 20 months. She had a lot of

referred pain in the left leg and often pain in both legs when sitting and lying.

66

Mandy had already seen five different neurosurgeons at the time of the

referral, none of whom seemed to be able to find a definite cause for her

lower back pain. Three weeks earlier, her current neurosurgeon had

performed a joint block in an attempt to alleviate her pain. She had been very

optimistic because she felt some action was finally being taken. However, the

procedure provided no relief and seemed, in fact, only to make her pain

worse. Her husband, Dylan, stated in the first telephone call that they both felt

as if they had reached the end of the road, with no idea where to go next.

Mandy, Dylan and their two sons (17 and 14 years of age) were present at

both the first and second session, which took place on consecutive Saturdays

in their home. Mandy and Dylan had been married for 20 years, and were

both involved in the field of education. Mandy had been teaching music for

most of her life. She stated that she still enjoyed it, because of the one-on-one

nature of this type of teaching. Mandy had, however, been off work for two

months at the time of the first meeting.

Mandy demonstrated an immediate need to talk about her pain. She

explained that she had gone the path of seeking medical help without any

discernible benefit. She blamed the doctors for their inability to cure her and

felt angry at and abandoned by the medical community. Dylan admitted to

sharing these feelings.

Mandy believed that her pain had affected her family. She stated that it felt as

if the pain, rather than her family, had become the centre of her life. She

67

admitted that she had withdrawn from her family to a great extent, because

she was so "wrapped up in" her pain. She admitted feeling as though she was

"losing" herself, and felt as if her pain determined her whole personality.

Dylan said that his dominant feeling was one of helplessness after seeing so

many doctors, with no answers forthcoming. He admitted that he was starting

to feel depressed, but felt like he had to stop himself from feeling that way,

because Mandy was "so down": "What will happen if I get depressed too?" He

admitted to finding it all very stressful. He stated: "Pain is becoming the centre

of my life too and I have had enough of it. I don't want to hear about the pain

anymore; it's all we talk about."

Both of Mandy's sons stated that the time she used to spend with them had

been affected. They were both active sportsmen, but Mandy no longer went to

watch them play sport at school as she did in the past. Her oldest son stated

that someone had asked her recently what position he played in the rugby

team and he was saddened to realise she didn't know. Both boys admitted

that they no longer wanted to talk to her, as "all she talks about is pain". They

both complained that she no longer spent the time with them that she used to.

MMFF Assessment

The MMFF was used to determine the level of family functioning in the six

areas. The MMFF was started during the first session and completed a week

later in the second session.

68

Roles

Epstein et al ( 1981, 460) define roles as "the recurrent patterns of behaviour

by which individuals fulfil family functions" The necessary family functions can

be divided into "instrumental" and "affective" domains. Instrumental roles

consist primarily of those functions related to the provision of resources, life

skills development, and maintenance and management of the system. The

affective roles include nurturance, support and sexual gratification of marital

partners.

Instrumental roles

With regard to provision of resources, Mandy's occupational role had been

compromised. Mandy's neurosurgeon had not booked her off after the joint

block. She found that she couldn't cope at work and got her GP to book her

off for six weeks. As a piano teacher she had to sit for extended periods and

she physically couldn't manage that. On one occasion, while sitting at the

piano, her back went into a very bad spasm. She then started to become

anxious before each class, in anticipation of a possible spasm.

Mandy was very afraid of permanent loss of functioning and what it would

mean. She feared losing her job, as both of their sons were at private schools

and she was worried about not bringing in the money she usually did.

Mandy's sense of worth and self-esteem had been affected and she felt she

was not pulling her weight and contributing to the family. Dylan agreed that

finances were a worry. Dylan stated that he believed Mandy was ready to give

69

up and that the six weeks she was booked off were the beginning of her never

going back to work, rather than time to recover.

Generally, Mandy was afraid of hurting herself and, therefore, engaged in

protective behaviour. She limited what she did on a daily basis. She stated

that she felt overpowered by the pain and relieved when each day came to an

end.

With regard to life-skills development, tasks necessary to help the children

complete school had been affected. Mandy no longer made herself available

to help the children with homework and no longer took an active interest in

their life at school, including going to watch them play sport or discussing their

day at school. Dylan had to take responsibility for these tasks.

Affective roles

With regard to affective roles, nurturance and support between the patient and

spouse, nurturance and support between the patient and children, and adult

sexual gratification had all been affected. Mandy felt her pain had become a

barrier between her and the family. She admitted feeling guilty about it, but

still preferred to isolate herself in her room each day. On his part, Dylan

admitted to being tired of sitting with the boys, while she was lying on her own

in their room. Dylan not only had to become mother and father to the boys,

but had also lost his sexual partner. Dylan said he found the whole situation

stressful and tiring, and he wanted them to be able to do the things they used

to do.

70

Communication

Roy (1989) states that effective communication is not easily achieved in

families with chronic pain. The reasons for this are multiple. For one, massive

role changes occur and, under these circumstances communication invariably

undergoes significant changes. Communication is also affected because of

the nature of chronic pain - a vague and ill-defined condition. Is he/she sick?

How sick is he/she? This makes direct and clear communication difficult, and

family members and patients are seriously compromised in their ability to

express their true feelings about each other.

Communication in this family had definitely been affected. Dylan found he

could not express negative emotions. He found himself holding back his

negative feelings and anger because Mandy was in pain and he didn't want to

add to her suffering.

Dylan and the children admitted to finding it hard to know how to relate to

Mandy. She had become increasingly absorbed in her problem, and Dylan

and the children no longer wanted to talk to her because all she talked about

was pain. Mandy agreed that she seemed to have lost her ability to

communicate positive feelings.

Affective involvement

Affective involvement encompasses the quality and extent of involvement that

family members have with one another. Roy (1984) states that the picture that

is likely to emerge in a family with a chronic pain sufferer is complex and

71

multi-dimensional. Depending on the part of the subsystem under scrutiny, the

nature of involvement can vary. Roy (1989) states that chronic pain can

induce dependency, anger, frustration and depression.

In this family, Mandy demonstrated a lack of involvement, because of her

withdrawal, as well as narcissistic involvement, which Epstein and Bishop

(1981) define as involvement where the investment in others is primarily

egocentric and there is no feeling of the meaning a particular situation holds

for others.

Dylan demonstrated a well-meaning over-involvement towards Mandy, which

became evident when he was the one who made the initial contact and made

all the arrangements to meet for the first time.

Affective responsiveness

According to Roy (1984), affective responsiveness has two groupings: welfare

emotions exemplified by responses such as love, happiness, and joy and,

secondly, emergency emotions such as anger, fear, sadness, disappointment

and depression. A wide range of emotional responses is desirable for an

effectively functioning family.

Mandy shut herself off and, therefore, Dylan and the children found it difficult

to express affection and caring for her. Mandy did express emergency

emotions such as anger, sadness, disappointment and fear of being

72

controlled by her pain. Dylan and the children responded with sadness, but

tended not to express their emergency emotions.

Problem solving

Problem solving involves the family's ability to resolve problems at a level that

maintains effective family functioning.

When does a medical problem become a family problem? Roy (1984) states

that with chronic pain, it grows slowly and almost imperceptibly. There is hope

initially that a medical cure will be affected. Gradually, however, this optimism

sours as the patient begins to recognise, as he/she makes his/her way

through the medical mill, that a cure is not at hand. The patient also receives

conflicting messages about his/her condition from different physicians.

Roy (1984) believes that repercussions of all this on the family may not be

immediately apparent, because the family continues to view the patient in

his/her usual role. But as the problems persist and the patient fails to resume

normal roles, tensions begin to mount and questions about his/her status

begin to be hesitantly and then forcefully raised. Is she sick or not? Some

doctors conclude there is nothing wrong. So why does she act so strangely?

Is she mentally ill? As the patient becomes more entrenched in the sick role

the problems assume serious proportions.

According to Roy (1984), families with a chronic pain patient tend to have

considerable difficulty in identifying problems, let alone reaching a consensus.

73

This problem is attributable to the very nature of the chronic pain syndrome

with its gradual onset and the ever-present hope for a medical cure.

Roy (1986) states that problems can be subdivided into instrumental and

affective categories. Instrumental problems are the practical ones that people

are likely to encounter on a day-to-day basis and may include issues such as

social activities and money management. Affective problems are related to

relationship issues. The family with a chronic pain patient often has a number

of problems in the domain of problem solving, especially as they relate to the

affective areas. They tend to explain all problems on the basis of the patient's

pain and that, of course, is beyond their solution.

With regard to instrumental problems, both Mandy and Dylan stated they were

unhappy with their social life and demonstrated an inability to solve that.

Their social life had been badly affected. They had limited contact with friends

and they didn't go out as a family anymore. Dylan said he couldn't remember

when they last went to a restaurant and hated that they'd become a "take-a

ways family". Activities they used to enjoy together were now a problem;

Dylan stated they used to be "movie people". Mandy admitted that she had

also withdrawn from her friends. She became very annoyed when, after no

definite cause for the pain could be found, well-meaning friends started to

suggest that maybe she was "just a bit tense and anxious". She hated the

idea of "supposed friends" starting to think she was just using the pain as an

excuse not to do things.

74

Both Mandy and Dylan perceived their spending their evenings in two

separate rooms as a problem. But that is more or less where it stayed.

Epstein et al. (1982) describe effective problem solving as a sequence of

seven steps:

1. Identifying the problem

2. Communication with appropriate people about the problem

3. Developing a set of possible alternative solutions

4. Deciding on one of the alternatives

5. Carrying out the action required by the alternative

6. Monitoring the action

7. Evaluation of success

Mandy and Dylan did not move beyond the identification step.

With regard to affective problems Mandy realised she had withdrawn from her

family. She felt guilty about it, but, again, there was no movement beyond the

identification stage. Mandy and Dylan were also unwaveringly focussed on

the problem of pain, while finding answers to family problems had a very low

priority.

Behaviour control

Behaviour control is the pattern the family adopts for handling behaviour in

three types of situations (1) physically dangerous situations (2) situations

involving the meeting and expressing of psychobiological needs and drives

and (3) situations involving socialising behaviour both inside and outside the

family.

75

The rules in this family had definitely changed. Mandy and her pain now set

the rules with regard to aspects such as their sexual life and social life.

Flexibility and spontaneity had become replaced by rigidity.

Dylan admitted to feeling controlled by Mandy's pain because the headaches

interfered with things like their social plans. He also felt the pain had taken his

control away in that he couldn't do anything to help her, even though he really

would have liked to. He admitted he was not used to finding himself in

situations that he could not control.

The rest of the second session was used to allow Mandy to complete the Brief

Pain Inventory (BPI) for the first time (see figure 4.1), and to discuss Mandy

and Dylan's expectations of hypnosis.

Brief Pain Inventory

Mandy completed the Brief Pain Inventory for the first time (see figure 4.1 and

4.2). As stated in the research design chapter, with regard to the pain severity

items, the pain worst item, rated on a scale of zero to ten bounded by 0 = no

pain and 10 = pain as bad as you can imagine, was chosen as the primary

response variable. The other three pain severity items served as a check on

variability.

76

With regard to the seven pain interference items, each rated on a scale of

zero to ten bounded by 0 = does not interfere and 10 = interferes completely,

the mean of these scores was used as a pain interference score.

1 0 '"'"''-·"'-''"-···-,---···-·----..... ,_,_ 8+---------------~ 6 -6 4 ~-t--"------------~ /..._Pain at worst /

2+------------1 0+-~--~~--~~~

Figure 4.1 First Completion of BPI by Mandy: Pain at worst rating

10 8 6 4 2 0

-6.1

'

_._Average of interference items

Figure 4.2 First Completion of BPI by Mandy: Pain Interference Score

Expectations of hypnosis

When asked what she believed hypnosis to be and what she expected from it,

Mandy's first reaction was that it was a deep form of relaxation that might help

her take her mind off the pain. She also stated that it might relieve some of

her fear and anticipation of spasms if she could learn to relax her muscles.

77

Mandy stated that her pain left her feeling helpless and out of control and she

desperately wanted to feel some degree of control of her life again. She said

she needed to feel that the pain had not taken over her life and who she was.

She wanted to feel like she was more than the pain and she didn't entirely

want to lose the life she led before the pain began.

Dylan agreed that he thought it might make her relax more and cope better.

He wanted to know if he could be involved in some way, because he felt very

shut off and very helpless.

In answer to current medications, Mandy indicated a painkiller and anti

inflammatory, but indicated that they gave her no relief. She also indicated

that she could not sleep unless she took a sleeping tablet.

It was decided to schedule the third session (first hypnosis session) for the

following Saturday in their home, and both Mandy and Dylan agreed to attend.

First hypnosis session

The session started with Mandy commenting on how she had been feeling in

the past week. She stated that she felt more positive. She said she was tired

of being in a passive position in dealing with her pain. She no longer felt good

about simply taking her medicine and following medical advice, and hoping for

the best. She felt more willing to believe she could do something to change

the situation. Dylan expressed how pleased he was to see a change in her

and again stated his need to help and be involved.

78

Mandy filled in the BPI for the second time (see figure 4.3 and 4.4).

10 8 6

4

2 0

_6 _6

F!-Pain at worst I '

Figure 4.3 Second Completion of BPI by Mandy: Pain at worst rating

10~----~~---·-~-----~~···-·-·-,

8+---------------~ ~--------~ 6 a...~S 1 ~Average of

-. 0.4 interference 4+---------------~

items 2+---------------~ ~--------~

·0(;,- ·0(;,-01<';$ ~ ~ ~ 0~ 0~

~() '00 ~<:0 ~").."'

Figure 4.4 Second Completion of BPI by Mandy: Pain Interference Score

Before the session, Dylan had asked Mandy whether she would mind if he

were to be hypnotized with her, as he felt a need to be involved in the

process. Mandy consented. In this first hypnosis session the induction

centered on simple relaxation techniques, as this appeared to fit with their

expectations. A progressive relaxation was done and then the couple was

asked to imagine going down a flight of stairs to a place that each would like

to see as safe, and peaceful and calm. After asking them to take in their

special place with all their senses, the couple was instructed to open their

eyes in their own time. Dylan opened his eyes almost immediately, but Mandy

79

remained with her eyes closed for a long period of time. When she finally

opened her eyes, each was asked to describe the place they had imagined.

Dylan described a beautiful forest, which he imagined walking through.

Mandy, who had already mentioned her love of her garden, saw herself

walking in a beautiful garden which extended as far as the eye could see in all

directions. She described the scene vividly; right down to the white dress she

was wearing blowing in the wind. She stated that God was in the garden with

her. She stated that she felt very safe and peaceful and protected. She said

she believed that if she kept praying God would help to heal her.

Mandy stated she had felt very relaxed and saw herself as very mobile while

walking in this garden. She said that for the first time in a long time it was

possible to ignore the pain for a while. She stated that she had not wanted to

leave the garden.

I commented that Mandy obviously missed going walking a lot and she

agreed with that. I asked her what exactly had stopped her walking, as she

did not appear to have difficulty walking the few times I had met her. She

replied that it was the fear of a back spasm that kept her from walking, her

fear of hurting herself. I asked her if she would consider just walking around

the block in the coming week with Dylan. In that way he would be there if

something happened to her or if she did go into spasm. She agreed to try, and

Dylan seemed pleased to have some role to play.

The next appointment was scheduled for the following Saturday in their home.

80

Second hypnosis session

The session began with Mandy completing the BPI for the third time (see

figure 4.5 and 4.6). The Pain Interference Score appeared to be lower due to

Interference with Walking Ability being rated a two as opposed to the rating of

nine the previous week.

10 -·--·=--·----~----, ! 8 -1-----------l

6 ... 6 ... 6 I r-----------, 4 +---"-----".-:-4 ___ ------ll !_._Pain at worst I

I 2 l 0+--..,--r--,----,..-..,....-~

0'5::- ·0'5::- ·0'5::~ ~ ~

~0 ~0 ~0 0 I$' 01$" 01$"

~o ),.o ),.o "co rv~v r~:>"-v

Figure 4.5 Third Completion of BPI by Mandy: Pain at worst rating

10 ________ ., ________ _

8+---------------l ~------~ 6 ..,.6.1 5_4 -..--.5 4+----------------l


2-t-------------------l L-----~

0+---r--r---r--"r""""-r-------l

·0'5::- ·0'5::- ·0'5::~ ~ ~

~0 ~0 ~0 01$" 01$" _(')~$"

~v ),.v ),.cr "co rv~\J' n}\J'

Figure 4.6 Third Completion of BPI by Mandy: Pain Interference Score

When asked to comment on the lower rating for Interference with Walking,

Mandy was visibly pleased. She stated that the day after our last session she

and Dylan had gone for a walk around the block. It had felt wonderful to be

outdoors in the sun and walking in the neighborhood she loved. She felt so

good that she went out the next morning on her own, after Dylan went to

81

work. She said she was amazed to find that her muscles actually felt "looser"

and felt less likely to go into spasm. The two of them had also been walking

together before the current session. She stated that the walking did make her

a little tired, but that she would lie down afterwards and sleep, rather than just

lying on the bed feeling sorry for herself. The walking made her feel like her

"old self".

Dylan stated how proud he was of her and how good it felt to see her up and

about again. He joked that she was still fitter than he was, and that he was the

one battling to keep up. Mandy was visibly pleased by this comment. Dylan

stated that her mood was "200% better" and that she had mentioned the word

"future" for the first time, even if it only related to going walking in the botanical

gardens the next week.

Mandy stated that she had felt very relaxed after the previous session. She

said that she had been trying to go back to her imagined safe place herself,

because it was so pleasant. She expressed a desire to go back there again.

Dylan expressed a desire to be hypnotised with Mandy again; however, she

seemed agitated by this request. Mandy stated that she would prefer to be

hypnotised on her own, as she wanted to learn to control the pain herself. I

pointed out to Dylan that in the same way people relax in different ways they

also become hypnotised in different ways and that it was important to find a

unique method of hypnosis for each person.

82

I suggested to Mandy that she appeared to have a lot of "hypnotic talent", as

she had been able to go so "deeply" into hypnosis the week before, to the

point where she "didn't want to come out". I suggested that we take a chance

and try a technique that is only suited to people with a lot of "hypnotic talent",

namely glove anaesthesia. I asked her permission for Dylan to help me

induce the glove anaesthesia and she agreed.

A progressive relaxation was used once again, as well as imagery of going

down a flight of stairs to her imagined safe place. Once she indicated that she

felt totally relaxed, I started to give suggestions that her right hand was feeling

heavy and numb. I asked her to imagine all the feeling sLowly draining out of

her right hand. Dylan was asked to aid the process by slowly and steadily

stroking her hand from wrist to fingertips, so as to "aid the draining out of

feeling". Mandy was instructed to help the process by using the power of her

mind to tell her hand to become numb. The couple was instructed to keep

doing this until Mandy felt her hand was totally numb. After a few minutes,

Mandy said that her hand was heavy and numb.

At this stage Mandy was asked to lift her hand and to place it on her lower

abdomen. She replied that she could not move her hand at all and Dylan was

then requested to lift her hand and place it on her lower abdomen. Mandy was

further instructed to imagine all the numbness draining out of her hand and

through to her lower back, until her lower back felt filled with all the numbness

that had been present in her hand.

83

Mandy appeared very relaxed at this stage. I then introduced the image of a

healing white light surrounding her body. Mandy immediately started to smile.

She was asked to imagine the healing light moving throughout her body, and

cleansing and healing her as it did so. Mandy was then asked to open her

eyes when she felt ready.

Once Mandy had opened her eyes, Dylan expressed his amazement at how

numb her hand had appeared to become. Mandy said that both her hands

had actually felt numb, and that her lower back still felt numb even though her

eyes were now open and she was "no longer hypnotised". I commended her

on how well she was able to control the sensations in her body and noted that

very few people were able to exert such control over their bodily sensations.

Mandy stated that she was very surprised at her sense of control and said

that she had not thought it possible to do such things. Mandy also commented

that she had enjoyed the image of the healing, white light and that it made it

feel like God was helping to heal her.

As homework, Mandy and Dylan were instructed to keep up the walking.

Mandy was again commended on her "obvious natural talent" and instructed

to start experimenting with progressive relaxation herself during the coming

week. The next session was scheduled for the following Saturday in their

home.

84

Third Hypnosis Session

The session began with Mandy completing the BPI for the fourth time (see

figure 4.7 and 4.8)

.... 6 .... 6

10

8

6

4

2

0

- ~4 """"A --

!_._Pain at worst I

Figure 4.7 Fourth Completion of BPI by Mandy: Pain Severity Items

1 0 ,-.-.-·-"--"-·-~--···-·--····

8 +-----------! c---------,

6 +--4-... 6..,..-=1 .. 5::..:·___:_4_....,__5 ___ -------! - --4.9 4+----------l


2 +-----------1 [_ _____ __j

0+-.......,---r--r----r--.,---!

·0~ ·0~ ·0~ ·0~ ~ ~ ~ ~

~0 ~0 ~0 ~0 0~ 0~ 0~ &~ :...c; oc; ,_c;

"Cj "v~ O::J'\.> ~

Figure 4.8 Fourth completion of BPI by Mandy: Pain Interference Score

Dylan once more attended the session. Mandy stated that she had had a

good week and had been walking every day, with Dylan joining her when he

had the time. She said that she had been trying to do the progressive

relaxation herself, but found it difficult to talk her way through it. I suggested

that perhaps her talent lay in responding to the hypnotic suggestions rather

than making them, and asked how she would feel about Dylan talking her

85

through the relaxation. She agreed it was worth trying. I suggested that Dylan

guide Mandy through the relaxation and then introduce the image of the

staircase so that she could imagine herself walking down it to her "safe place".

I would then "take over from him".

Dylan started to talk to her, using much the same phrasing he had heard me

use for the progressive relaxation in previous sessions. He then introduced

the image of the staircase and Mandy was able to imagine herself walking

down the stairs and to her safe place. The glove anesthesia exercise and the

image of the healing white light were then repeated as in the previous

session. Mandy reported feeling very good afterwards and reported being

quite satisfied with Dylan leading her through the progressive relaxation. She

stated that she found his voice quite soothing.

For homework the couple was instructed to keep walking, as well as to

practice the progressive relaxation with Dylan guiding Mandy and then

introducing the image of the staircase so that she could "reach her safe

place". Additionally, I asked Mandy and Dylan to start to think about ways to

help Mandy cope better when she went back to work. The next session was

scheduled for the following Saturday in their home with Mandy and Dylan to

attend.

86

Fourth hypnosis session

The session began with Mandy completing the BPI for the fifth time (see

figure 4.9 and 4.10).

10

8

6

4

2

0

_6 __ 6

"'4 ~5 !_._Pain at worst I

Figure 4.9 Fifth completion of BPI by Mandy: Pain Severity Items

10 8 6 4 2 0

... 6.1 F\ 4 A 1"\

·0~ ·0~ ·0~ ·0~ ·0~ 0-.:s~~~~ ~ ~ ~ ~ ~ o~ o~ o~ _o~ o~ ,._o )..o )..o u- o

to.. Co t-v~\.> O:>'\.> ~ <o'"S'

I 4.7


Figure 4.10 Fifth completion of BPI by Mandy: Pain Interference Score

Mandy's rating for Interference with Walking was now down to a one as

opposed to the original rating of ten. Mandy and Dylan reported that they were

planning to go on a day hike with the boys. Dylan joked that maybe they

would become "walking people instead of movie people".

87

Both reported that practicing the progressive relaxation had been going well

and that they enjoyed this quiet and peaceful time together.

Mandy reported that they had spent some time talking about how she would

cope once she returned to work. She said she had decided to spend more

time teaching the flute, instead of the piano. She had a lot of requests to teach

the flute and it was something she enjoyed. She stated that maybe this was a

chance to try something new, rather than just trying to force herself back into

her old life. If she taught the flute and the piano she could alternate sitting and

standing. She stated that her schedule could also be flexible and she

wondered whether she could use her self-hypnosis in quiet times between

classes. As Dylan would not be present at these times, they asked me about

the option of making a tape. I agreed that it was a good idea and suggested

that Dylan, therefore, took Mandy through this session, with me there to help

him if he "ran out of words or got stuck". We once more did a progressive

relaxation, and used the image of descending the staircase so that Mandy

could reach her safe place. Once she indicated that she felt relaxed, the

couple used the glove anaesthesia exercise and Dylan introduced the image

of the healing white light. I commented after the session on what a wonderful

team they made and how positively they could tackle this problem together.

For homework the couple were instructed to keep walking and to make their

tape and bring it to the next session, scheduled for the following Saturday.

88

Fifth hypnosis session

The session began with completing the BPI (see figure 4.11 and 4.12).

10~·--·--·---~-·-·-·--·-~·--· .. ,

8 +------------1 6

6 ~~-----------1

4 +---~----!":..__~o.-------1

2 +------------1

0 +---,.-....,.---,.--,.-_,_,.-----1

I~Pain at worst I

Figure 4.11 Sixth completion of the BPI by Mandy: Pain Severity Score

10 8 6

4

2

0

.... 6.1 5.4 c: - :::' A Cl -~

4.7 3. ~

-o~ -o~ ·o~ -"~ -"~ -"~ ~ ~ ~ ~v ~v ~v ~0 ~0 ~0 ~0 ~0 ~0

~~ ~~ ~~ ~~ ~~ ~~ cP cP cP o0 o0 o0

"-q o/:> O:>'O. ~ <o~ ~

~Average of interference items

Figure 4.12 Sixth completion of the BPI by Mandy: Pain Interference score

The Pain Interference score was lower on this completion, due to the rating

for Interference with sleep decreasing for the first time. Mandy stated that, for

the first time in months, she had had a night of sleep without a sleeping tablet.

89

Mandy was now walking every day and said she felt confident that she would

cope when she went back to work. She stated that she had gained a new

perspective on pain. She said she no longer expected to be pain-free, but she

did now expect to cope and get on with life. She felt she could now live rather

than merely survive.

Dylan stated how proud he was of her and how glad he felt for having played

some role in helping her.

The couple had made their tape during the week. Mandy stated that she

found it effective in helping her to relax and that she was planning to use the

tape in her free periods once she was back teaching.

I suggested to Mandy and Dylan that we made this our last session as they

were now coping so well and were obviously an effective enough team to take

on this battle alone. They agreed that they felt that together they could do this

and that we could end our time together. A feedback session was scheduled

for two weeks later in their home.

Feedback session

Mandy had by now returned to work. She stated that though she was finding

it tiring, she was coping. She kept a foam mattress in her classroom and if she

had time off between classes she listened to her tape and relaxed. She stated

that she enjoyed feeling like Dylan was there with her. Mandy was now

teaching the flute and the piano and found this helpful physically, as she no

90

longer sat for extended periods of time. Mandy and Dylan continued to walk

and the family had been on a day walk the previous weekend.

Mandy felt that she had benefitted from our sessions. She stated that she still

experienced pain on a daily basis. However, she felt the pain was no longer

the center of her life. It had now become just a little corner, which at times she

was not even aware of.

Meta perspective

A feature of ecosystemic therapy is the need to join the with the clients'

consensual domain. From our initial conversation it seemed as if the

consensual domain within which we were situated adhered to the following

ideas: hypnosis can help with relaxation and allow the mind to exert some

control over the body. The issue of control appeared central to Mandy. She

felt as if her old life was slipping away. Using glove anesthesia could well not

have been successful. However, it was worth attempting because it is a

technique which sets the client up as having control over his /her bodily

sensations. Fortunately, it worked well with Mandy and became a mainstay in

her pain artillery. The imagery of a healing white light also appeared to be

effective because it joined with Mandy's idea that God could help to heal her.

During the sessions Mandy and Dylan were "taught " to make use of self

hypnosis. From a contextual point of view, an ecosystemic stance seriously

questions the usefulness of the concept self-hypnosis (Lifschitz and Fourie,

1985). The notion of self-hypnosis, form an ecosystemic viewpoint, is seen as

91

an artifact of the state conception in which hypnosis came to have a reality of

its own. As Lifschitz and Fourie (1985) state, this does not imply the rejection

of the strategic utilization of self-hypnosis in the context of therapy.

From our initial meeting it also became obvious that pain was splitting the

family up and isolating members of this family. Mandy's reaction to pain was

to isolate herself, but this ignored Dylan's need to be there for her and help

her. Dylan was left feeling inadequate and helpless. There was a very real

need to unite these two in doing something active and positive to combat the

pain, and with their mutual love of the outdoors, walking filled this purpose.

Involving Dylan in the hypnosis also helped build this supporting relationship.

Mandy did a lot of talking in our first two sessions about what it meant to be in

pain. She had a lot of fear, as well as anger, related to whether people saw

her pain as real. Just letting her know that I accepted her pain as real

appeared to very helpful to her. She appeared to have a need to feel that

someone was paying attention and believed her, and having this need fulfilled

appeared to be therapeutic in itself.

With regard to the BPI, Mandy's pain at worst rating had decreased from a six

to a three over the course of the sessions. Her pain interference score had

decreased from a 6.1 on the first completion of the BPI, to a 3.4 on the last

completion of the inventory.

92

4.2 DUDU

Dudu, her husband and their daughter, Lindy (20), were present at our first

session, which was held in their home on a Sunday afternoon. Dudu's

husband had made a special effort to attend, as he normally was busy with

work on weekends. Dudu also has two sons, but both were away at university.

Dudu had been suffering from low back pain for three years. She had already

had surgery twice. The second operation, a spinal fusion, was performed

eleven months prior to our first session. Dudu stated that her reaction to pain

was not to slow down, but rather to "put the pain in the back of my mind and

carry on". She stated that she still tried to be as active as before and didn't

relax much.

Dudu stated that she hated her children to see her in pain and that she hated

to see them upset when they visited her in hospital after her two operations.

She was in hospital for a month both times and then at home for three months

after each operation. She admitted to getting very depressed when she was

bedridden, but said that she did not want her family to know how she felt. Her

husband expressed surprise at this and said that they had all believed she

was coping just fine.

MMFF Assessment




93

Roles

With regard to instrumental roles, Dudu's occupational role was initially

affected by the time spent in hospital and then at home recovering after each

operation. At the time of these sessions, however, Dudu was working a full

day and refused to let her pain interfere with her work, to the point where she

at times was in danger of hurting herself because she did too much.

With regard to instrumental roles, it appeared that Dudu was still very

nurturing towards and supportive of both her husband and children. The

marital relationship also seemed to be characterized by love and affection.

Dudu remained an active participant in all aspects of family life and still took

joint responsibility for making sure the family was well provided for.

Communication

Dudu's daughter, Lindy, stated that even when Dudu was in pain she and her

brothers found her very approachable and they were not afraid to share their

problems with her. Dudu's husband agreed that, even when she was in pain,

she communicated support and encouragement to him and the children.

What did appear to be problematic with regard to communication was that

Dudu did not share emergency emotions, as she felt the need to protect her

family's feelings.

94


This family appeared to demonstrate empathic involvement. Epstein and

Bishop (1981) believe this to be the most effective type of affective

involvement and define it as an emotional involvement in other family

members in which each member cares deeply about the significant activities

and involvement of the others. This family appeared to demonstrate true

affective concern for the interests of others in the family.


A lot of welfare feelings were expressed in this family. However, Dudu did not

express emergency emotions, even though other members of the family felt

free to express their emergency emotions. Dudu kept her sadness and

depression to herself.

Problem solving

This family effectively dealt with practical, day-to-day instrumental problems.

Notably, areas such as social activities and money management had not bee·n

very affected by Dudu's pain problem.

The affective domain was, however, problematic. Dudu's need to protect her

family from her pain was not even identified as a problem, let alone dealt with.

Tunks (1990, p.245) discusses the problem of "the patient who copes well".

These patients present an image of strength or are seen as admirable. The

disadvantage is that more appropriate behavioral repertoires in line with their

problems have not been developed. They seem to feel an obligation to be

95

immune to their problem and not to impose their difficulties on the family.

Tunks (1990) states that these patients need to learn more appropriate

adaptive responses. They need to learn to ventilate feelings rather than push

themselves to the point of breakdown, and they need to set limits on

themselves and others.

Dudu appeared to negate her need to share not only positive, but also

vulnerable feelings. Dudu also needed to inform the family when she was pain

and not simply leave it to their imagination or powers of observation to find

out.

Behavior control

This family appeared to be well organized with clear family rules. Behaviour

control was fairly rigid though in that there appeared to have been very little

change in behavior control since the onset of Dudu's pain. The family still

stuck to the same rules of who did what. There should perhaps have been an

opening up, with more of a give and take situation and a moving in by other

family members to take up the slack.

The rest of the second session was used to discuss the family's expectations

of hypnosis and to allow Dudu to complete the BPI for the first time.


Both Dudu's husband and daughter thought that hypnosis might help Dudu

relax and, therefore, feel less pain. Dudu stated that she "hoped" it was about

96

relaxation. She said she didn't think hypnosis could remove the pain, but that

it could maybe make it something she could cope with.


Dudu completed the BPI for the first time (see figure 4.13 and 4.14). Her Pain

Interference score was only 2.6, which was consistent with her reporting that

she did not let her pain interfere with her life.

1 0 ·--·-~-~~---,-~~----.,-----~-

8+-----------! 6 ... 6

4+------------! 2+------------! 0+--..,...-,----,---r--r---!

J-4-Pain at worst l

Figure 4.13 First completion of the BPI by Dudu: Pain at worst rating

10 ----------·---·-·--., 8+-----------~ ~--------~ 6 +----------l -4-Average of

interference 4 +-----------l items 2~·~2=·=6 ______ -! L--------~

0+-~--~~--~-..,...----!

Figure 4.14 First completion of the BPI by Dudu: Pain Interference score

The idea was introduced to the family that perhaps Dudu would appreciate

someone attending the sessions with her, so as to encourage and support

her. Her daughter immediately indicated that she would like to remain

97

involved in the process. She stated that her father had to work on weekends,

but that she would like to "help mom out".

It was decided to schedule the third session (first hypnosis session) for the

following Sunday in their home, with Dudu and Lindy to attend.


The session began with Dudu completing the BPI for the second time (see

figure 4.15 and 4.16)

10 8 6 4 2 0

_6 -...s I 1-e-Pain at worst I

Figure 4.15 Second completion of the BPI by Dudu: Pain at worst rating

10~-~-·--~~·--------·~

8 +--------------4 ~-----~

6 +---------------4

~ ~?4 i 0+-........,.-...,.....-,----,--.,----4

·0~ ·0~ ~ ~

~0 ~0 0~ 0~

)'... c; ?:> c; "<"0 I);~

-e-Averageof interference items

Figure 4.16 Second completion of the BPI by Dudu: Pain Interference Score

98

Dudu reported that she had a good week. Her daughter stated that she was

looking forward to "being there" for her mother as "she's always there for me."

Dudu made herself comfortable on the couch. She asked if she should close

her eyes and I told her to do whatever came naturally to her. She then closed

her eyes. Dudu was instructed to breathe deeply and to focus on her

breathing. I then began to metacommunicate with her daughter. I pointed out

that Dudu's breathing seemed to be getting deeper and slower and Lindy

remarked that Dudu's facial expression was relaxing too. I took hold of Dudu's

right wrist, lifted it above the arm of chair and commented on its heaviness. It

was noted to Lindy that this was a clear indication of the depth of relaxation

Dudu had achieved. Lindy was then asked to lift Dudu's wrist herself to also

verify the heaviness.

Dudu was then asked her to imagine herself in a very peaceful and relaxing

place and to indicate by nodding her head when she felt totally relaxed. At this

stage the reframe was introduced that, while it was admirable for her to be a

loving mother who felt responsible for her children and husband, she was

ignoring her own needs and feelings. It was suggested that by placing the

needs of others before her own, she was losing touch with herself and that

she needed to be a complete person if she was to be there for her family. I

suggested that it was crucial that she learn to accept and fulfil her own needs

if she was to help others. I commented that she needed to let others help her

and listen to her.

99

Dudu was instructed to rouse herself by counting up from ten to zero silently,

and then opening her eyes. Dudu opened her eyes and reported feeling very

relaxed.

Lindy stated that her mother had looked "incredibly at peace" and said that

she too would like to "experience hypnosis". I suggested that hypnosis might

be something that Lindy could "do for Dudu". It was agreed that Lindy and

Dudu would be hypnotized together in the next session.

For homework Dudu was instructed to ask her family for help with at least one

household task each day, no matter how small the task. The next session was

scheduled for the following Sunday in their home, with Dudu and Lindy to

attend.


The session began with Dudu completing the BPI for the third time (see figure

4.17 and 4.18).

.,6

10 8 6 4 2

0

~ -<+

!

' ! !_._Pain at worst I

I

Figure 4.17 Third completion of the BPI by Dudu: Pain at worst rating

100

10 8 6 4 2 0

.._L.O 2.4_ 2 3

·0-c::- ·0-c::- ·0-c::-~ ~ ~ ~ ~ ~

0~ &~ &~ ~q. v rfO. n:,"-0.

I


Figure 4.18 Third completion of the BPI by Dudu: Pain Interference score

Dudu reported that she had a good week. Lindy said that Dudu had asked for

help during the week and, in response, Lindy had cooked supper on two

occasions. She stated that she quite enjoyed the cooking and that she liked

the time it gave her parents to relax, as they both worked very hard. Dudu

stated that it had been good to relax a little more than usual.

It had been agreed in the previous session that Dudu and Lindy would be

hypnotised together. In order to punctuate what was about to happen as

hypnosis, we set them up in two chairs facing each other. I asked them who

they thought would "go into hypnosis" first. Both agreed that, because of her

previous experience, Dudu would. At this point Dudu closed her eyes. Lindy

closed her eyes a minute or so later. I began to speak softly to them, asking

them to breathe slowly and deeply, and then took them through a progressive

relaxation exercise. The pair was then asked to imagine a staircase consisting

of ten stairs and to imagine descending those stairs, in their own time, to a

place they felt safe and comfortable in. Once they had reached their imagined

101

safe place they were asked to "take in the place with all their senses" and

then to ascend the stairs again when each felt ready and open their eyes.

Once both the women had opened their eyes, Dudu reported feeling very

relaxed and pain free. She stated that the safe place she had imagined was

the ocean. Lindy stated she had felt very connected to her mother even

though her eyes were closed. Dudu and Lindy were instructed to practice the

breathing and relaxation exercise, as used in the session, at home. Dudu was

also instructed to keep asking for help with household tasks, although she

could decide how frequently she did so. In addition, she was instructed to tell

her family when she was experiencing pain, not so that they felt they had to

do something about it, but so that they would know how she was feeling.

The next session was scheduled for the following Sunday in their home, with

Dudu and Lindy to attend.


The session began with Dudu completing the BPI for the fourth time (see


10 ··~---·-·-·--8+----------------l 6~~-~-----------j ~-----~

1---Pain at worst I 4 +----=----=---=-3 ---------1 . . 2 +----------------1 0 +---,--r---,---.--..,--1

0~ -o~ o~ ·O~ ~ ~ ~ ~

~0 ~0 ~0 ~0 ~~ ~~ ~~ ~~

oo oo oo oo ...__q. f),~~ f?'~ ~

Figure 4.19 Fourth completion of the BPI by Dudu: Pain at worst rating

102

10 8 6 4 2 0

-~

___ L:.b. 2.4.? 3

-o~ -o~ -o~ -o~ ~ ~ ~ ~

~0 ~0 ~0 ~0 ~~ ~~ ~~ ~~

cPcPcP& "'q. "v~"t> n;;<.."t> ~

') 1 ~ -1

.,._Average of interference items

Figure 4.20 Fourth completion of the BPI by Dudu: Pain Interference score

Dudu and Lindy reported that they had practiced "with great success". Lindy

stated that Dudu had admitted to being in pain on two occasions during the

week. On both occasions they had used the breathing and relaxation and

Dudu had felt better afterwards. Lindy stated that she was continuing to help

out in the house, even if Dudu did not ask for help each day.

I asked Lindy if she would be willing to hypnotize Dudu, out of her experience

of the previous week and their practicing at home. Lindy agreed to try and

Dudu made herself comfortable on the couch. Lindy started to speak to her

mother in a soft voice, suggesting that she was feeling relaxed and peaceful.

She asked her to focus on her breathing and kept repeating words like "calm"

and "quiet". Dudu's eyes then closed. I mentioned to Lindy that Dudu's hand

was twitching and suggested this might be a sign of her muscles relaxing.

Dudu's head began to move to the left and Lindy noticed this and pointed it

out. At this stage Dudu nodded her head to indicate that she was totally

relaxed.

103

I suggested to Dudu that it might be good if she could attempt to transform her

pain "into something else" and in that way make it something she could cope

with better. Dudu was asked to visualize her pain and to "give it a form". She

reported seeing her pain as a solid red block. Dudu was then asked to

imagine the form of her pain changing. Firstly, she was asked to imagine the

edges of the block softening and losing their rigidity and becoming almost

fluid. She was then asked to imagine the colour changing from red to purple

and then to blue, until the colour resembled that of waves. It was suggested

that rather than discomfort she now felt coolness and refreshment. Dudu was

instructed to enjoy the sensation for as long as she needed and then to open

her eyes in her own time.

In the discussion of her experience, Dudu stated that she enjoyed the

exercise and that it had reduced her pain and left her feeling relaxed and

calm. Dudu was instructed to continue practicing her breathing exercises. In

addition she was to continue letting her family know how she felt and ask for

help when she needed it.

The next session was scheduled for the following Sunday in their home with


104


The session began with Dudu completing the BPI for the fifth time (see figure

4.21 and 4.22).

1 0 ------·-,·-~~-,~··'"'"'" _____ _,,,,, ___ ,,,

8+---------------~

6~~----~------~

4 1 1-e-Pain at worst j

2+-----------"""1~--l

0-t----r-.....---.--....---..,..--l

10 8 6 4 2 0

__ , ___ , ____________

.... 2.6 ~.4 2.3 2.1 -. 1.0

·0~ ·0~ ·0~ ·0~ ·0~ ~ ~ ~ ~ .,('~ ~0 ~0 ~0 ~0 ... ~

~<:< ~<:< ~~ ~~ ~~ o> o> cP cP v0

"?;- r-v~~ O:>'~ ~ <o.;s-


Figure 4.22 Fifth completion of the BPI by Dudu: Pain Interference score

The average of the Interference items was lower due to Interference with

Sleep now being rated a three as opposed to a six the previous week. Dudu

attributed this to her having more help in the evenings and, therefore, being in

less pain when she went to bed at night.

Dudu was instructed to relax herself, with Lindy assisting in the process by

speaking in a soft tone of voice and by directing her attention to relaxing each

105

group of muscles in turn. Once Dudu indicated she was relaxed, the previous

session's "transformation of the pain" exercise was used again. I then

commented to Dudu that she was now in a "sufficiently deep state of hypnotic

relaxation" so as to be able to present herself with a number of hypnotic

suggestions, which would aid her in overcoming her pain. The following

suggestions were presented to her: (1) that she could "transform" her pain

whenever feeling stressed or overwhelmed by pain and (2) that it was okay to

tell others when you are in pain and to ask them to help. Dudu was asked to

indicate her acceptance of the suggestions and her commitment to their

fulfillment. She was instructed to terminate the session by opening her eyes

when she felt ready.

Dudu was instructed to practice her breathing and the "transformation"

exercise at home each day. She remarked she felt very relaxed and "very

positive about trying it in my daily life".

The next session was scheduled for the following Sunday in their home with



The session began with Dudu completing the BPI for the sixth time (see figure

4.23 and 4.24).

106

10~-·~----·-·~--~-··~~--~--~~

8+----------i 6 I ~-~---~ 4 +----~a...o-------_j E!: Pain at worst I 2 2 2' -~-

0+----r-..,.------.---,----.,...---l

Figure 4.23 Sixth completion of the BPI by Dudu: Pain at worst rating

1 0 ~----··-·------·----.. -------·-·-.... 8+-------------!

6+----------l

~ +--.. --...f":P-_~.&.:r:."!-..---. .2"'. 3;:;---2-. 1-1-.6-1 .---~6

0+---r--,--.---,.---r---l


Dudu reported "great success" with her "self-hypnosis". She said that she had

been very tired one night and didn't want to "talk herself through". She had

then asked her daughter for help. Dudu reported a "definite decrease" in pain

and stated she found it very effective to "transform" her pain. I congratulated

her on her success, but stated that it was exactly what was expected because

of her strong will and determination to succeed.

It was agreed that this be the final session. A feedback session was

scheduled for two weeks time in their home with Dudu, her husband and

Lindy to attend.

107

Feedback session

Dudu appeared very relaxed at this meeting and stated she was "feeling

good". She reported practicing each evening before she went to sleep. She

stated that using her self-hypnosis before going to sleep, coupled with the

extra help in the house, was helping her to sleep better than she had in years.

Lindy stated that she was still enjoying being able to do something for her

mother. Dudu's husband stated he enjoyed the extra bit of time they got to

spend together, now that Dudu didn't feel she had to do everything herself. He

also enjoyed that Dudu appeared to be more relaxed.

Meta perspective

From the first session it appeared that the consensual domain we were

operating in was that hypnosis could help with relaxation and that, rather than

taking the pain away, it could help transform the pain experience into

something Dudu could cope with. Therefore, an approach was adopted that

would fit with these ideas. Relaxation was used from the first session and in

' the later sessions externalization was introduced. The problem was made a

separate entity and external to Dudu, so that she could change its fixed

qualities. In this way Dudu's pain was not taken away, but changed into

something,she could better cope with. The transforming of the pain appeared

to be made more effective by transforming it into a wave, which is associated

with Dudu's chosen "safe place", the ocean.

108

The MMFF assessment revealed that, although this family functioned

relatively successfully, Dudu was placing an unnecessary burden on herself

by insisting on coping with the pain on her own. The members of this family

did appear to care a lot for each other and, therefore, the researcher

introduced the idea that someone who cared for her became involved in the

therapy. A lot of the gains made by Dudu appeared to be related to her

realization that she didn't have to cope alone and that someone else could

understand the problem. Dudu needed to, and did appear to, accept the

requirement to depend appropriately on others.

With regard to the BPI, Dudu's Pain at Worst rating had dropped to two as

opposed to the first rating of six. The mean for the Pain Interference items had

dropped from the original 2.6 to 1.6.

4.3 EVE

Eve's first session was held on a Saturday afternoon in her home. Eve's

husband and two teenage sons (13 and 19) also attended. Eve had been

suffering from chronic lower back pain for six years. She described her pain

as sharp and burning. Her doctor, however, could not find a definite cause for

the pain on any X-rays, and told her he believed the pain was caused mostly

by muscle spasm. Sitting for a long period of time, climbing stairs and driving

long distances were all problematic for Eve. Eve stated that having her back

rubbed helped her, but that she did not often have the time to get to a

physiotherapist. As a result, Eve's husband and children were always getting

called on to rub her back. Eve's husband admitted that he was starting to find

109

this annoying: "We get little enough time together, and every time I do see

her, she wants me to rub her back." Eve's sons also admitted to "making a run

for it" whenever they saw her with her tube of anti-inflammatory gel. Eve

admitted that she had now taken to making the housekeeper rub her back for

her. Eve stated that if the pain could be taken away she could be more

independent, because she wouldn't always be looking for someone to rub her

back and she would be less irritable.

MMFF Assessment


areas. The MMFF was started in the first session and completed in the

second session on the following Saturday.

Roles

With regard to instrumental roles, Eve's work life had been affected very little

and she stated that she had very rarely missed work due to her pain. Eve and

her husband both had very demanding jobs, which involved long hours and a

fair amount of traveling. Eve stated that she refused to limit what she did and

admitted that she sometimes did too much and hurt herself.

Affective roles also appeared to be unaffected and, despite her pain, Eve

remained invested in maintaining a caring and supportive relationship with her

husband and children.

110

Eve appeared to still be an active participant in all aspects of family life. She

and husband took joint responsibility for making sure the family was well

provided for.

Communication

Eve stated that she would tell her family "quite openly" when her back was

sore. However, she tried not to take her pain out on others and preferred to

communicate "positive and supportive ideas" to her family. Her husband and

children agreed that she didn't tend to get "depressed or irritable" when in

pain and that they always found her approachable.


Although both parents worked long hours, this family appeared to

demonstrate empathic involvement, with each member caring deeply about

the significant activities and interest of the others. Eve and her husband

remained concerned and interested in each other's welfare. The couple also

took an active interest in and supported all their sons' activities. This family

liked to be seen as a team and members appeared to be very loyal to each

other.

111


This family appeared to have a wide range of emotional responses and

welfare emotions and emergency emotions appeared to be freely expressed.

Problem solving

The family appeared to deal effectively with practical, day-to-day instrumental

problems. Notably, areas such as social activities and money management

had not been affected by Eve's pain problem.

This family also did not appear to have difficulty with solving affective

problems. The family members were genuinely interested in and involved with

each other. They liked to see themselves as a team and tried to deal with

affective problems as a family: "If one of us is unhappy, we will try to figure out

why, and what we can do about it."

Behavior control

This family appeared to be well organized with clear family rules. Behaviour

control was flexible in that family members "pick up the slack" for each other.

For example, if Eve was traveling, her husband and the boys would help out

more.

The rest of the second session was used to discuss expectations of hypnosis

and to allow Eve to complete the BPI for the first time.

112


Eve's expectations were that hypnosis would teach her to relax and,

therefore, cope better with the pain. This was important to her because her

doctor believed her pain was related to muscle spasm. Eve's husband agreed

that relaxation was important, especially as she appeared to have more pain

at times when she was under stress or feeling anxious. Eve stated that she

thought hypnosis might also involve some sort of visualization and that she

had heard that the "deeper you went" the more effective hypnosis could be.


Eve completed the BPI for the first time (see figure 4.25 and 4.26).

1 0 --·-·-·-----·------,-·------1 8 • 7 ' ,-----------, 6+---------j 4+---------j

_._Pain at worst

2 ~--~

I 0+--.,.---,-.,--.,.---,---j

Figure 4.25 First completion of the BPI by Eve: Pain at worst rating

113

1 0 4""·~~-"·•· .... ·~·~·-~~,,.~---·lj

8 +--------1 ,--------, 6 I _._Average of

4 -f-*4- I interference items 2 ~--- ~~-'

0 +-..,...........,..-..,--,--....,.---j

Figure 4.26 First completion of the BPI by Eve: Pain Interference Score

Pain's overall influence over this family appeared to have been kept to a

minimum. Therefore, only Eve was scheduled to attend the third session (first

hypnosis session) to be held in their home the following Saturday.


The session began with Eve completing the BPI for the second time (see


10~-~--·--·-·---~----~-""1 8 +----=-------~---1 6 ~ a .--_...-~P~a~in~a-,t 4+----------1 worst 2 ~----'

0+--,.---..-,.--,---..,..--!

~0~ ~0~ '::,..0 '::,..0

~<y_ ~<y_ '!,..& 0.&

"-co ');~

Figure 4.27 Second completion of the BPI by Eve: Pain at worst rating

114

10

8

6

4

2

0

_4 3.7 ---.

1 ..._Average of

I interference I

----i items

Figure 4.28 Second completion of the BPI by Eve: Pain Interference Score

Eve stated that she was feeling excited and "very positive". Eve was asked to

make herself as comfortable as possible to increase the likelihood that she

would "relax completely". She felt she should lie on the couch and, once she

had made herself comfortable, she closed her eyes without being asked to. I

asked her to concentrate on her breathing and notice how this was connected

to any movement she might feel in the rest of her body. It was suggested that,

as she breathed in, her shoulders might begin to feel lighter. I then mentioned

that her shoulders were connected to her arms and hands. I suggested that

we wait for changes and suggested that perhaps her hands might begin to

feel lighter. I started to wonder aloud whether her left or right hand might start

to feel lighter first. At this stage her right index finger started to twitch. I

remarked on this, and suggested that her finger might continue to move on it's

own, and added that it might even begin to feel as if her whole hand wanted to

lift. I commented that it would be best not to make her hand lift, but to wait for

it to feel like it wanted to lift. I pointed out that her right thumb seemed to be

getting lighter and I continued in this vein, until her right hand had completely

levitated. I instructed her not to be afraid of this. I also asked her to notice how

115

it felt and then, when she was focused enough and felt ready, to open her

eyes and watch her hand. She opened her eyes and I suggested that when

she had seen enough she should close her eyes again and bring her hand

down under her own control. She was instructed to terminate the hypnosis by

slowly opening her eyes in her own time.

Eve stated on opening her eyes that the movement of her hand had surprised

her. She said that at first she had not been sure that she was hypnotized, and

that she had not thought she was that "deep" until she saw her hand. She

felt the experience had been very different to what she expected, and she had

enjoyed the "very unusual sensations" she had experienced. She stated her

body had "felt different" in trance. I commented that perhaps that "different

feeling" was preferable to the pain she normally felt and she agreed with this.

The next session with Eve was scheduled for the following Saturday in her

home.


The session began with Eve completing the BPI for the third time (see figure

4.29 and 4.30).

116

10 8 6 4 2 0

~6 -.....5

0~ -o~ o~ ~ ~ ~

§:0 §:0 §:0 6>~ 6>~ 6>~

"q. rv~~ O:>"~

l I _.,_Pain at

worst

Figure 4.29 Third completion of the BPI by Eve: Pain at worst rating

10

8

6

4

2

0

-~--~--~--

_4 3.7 ~ 2.9


Figure 4.30 Third completion of the BPI by Eve: Pain Interference score

Eve was asked to make herself comfortable and to concentrate on her

breathing, which then became progressively slower and shallower. Shortly

thereafter she indicated by nodding her head that she was completely

relaxed.

Eve was then asked to imagine herself in a large, airy lift, which descended

slowly to an imagined place that represented safety and comfort for her. Once

117

Eve indicated that she was in this imagined safe place, she was asked to

become aware of any pain present in her lower back and to focus her

attention on it. Eve had stated in the very first session that her pain tended to

be a burning pain. She was now asked to visualize her pain as a large, red,

burning ball of energy like the sun. She was asked to focus on it and to

imagine it slowly start to become smaller and smaller as she watched it. As

the ball appeared to become smaller, Eve was asked to imagine it beginning

to lighten and change colours from red to a soft pink to a pale blue. She was

asked to indicate when the imagined ball had become so small and pale that it

had disappeared completely. Once Eve indicated that it had, she was asked

to slowly lift her head and open her eyes.

Eve commented that she "felt very different again". She described it as a

pleasant and comfortable feeling. I suggested that by making her pain feel

different, it might make it possible for her to cope with it. Eve was instructed to

"hold onto" that feeling. I commented that she could now look to her imagined

special place to find that feeling and in that way cope with her pain

independently, instead of having to rely on someone being around to rub her

back. I suggested that now that she had had this experience she could access

it whenever she wanted to.


The session began with Eve completing the BPI for the fourth time (see figure

4.31 and 4.32).

118

101~'~'·~~--~~~~···~~-~~·-·-~····~~

8 +----------------{

6+--=~----~

4+--------"'~-----!

2 +-----------!

0+--r---r-,....---r----r---!

-e-Pain at worst

L_____ __ ___l

Figure 4.31 Fourth completion of the BPI by Eve: Pain at worst rating

1 0 .~·-·· .. -· .. -~---·--·--··---""''"""! 8 +---------! 6 +---------1

4 +-tlloo.ooor'---'-'---9--fr-----l

2 +----_..._.....c:::L_---l

0 -+--r---r-....,---r-..,r---1

-e-Average of interference items

Figure 4.32 Fourth completion of the BPI by Eve: Pain Interference score

Eve was asked to relax herself in the presence of the researcher by closing

her eyes, focusing on her breathing and allowing a sense of heaviness to

develop throughout her body. She was told that "at the appropriate moment"

she would be aided in extending the relaxation into hypnosis. Eve closed her

eyes and began to breathe slowly. After a few minutes, she indicated by

nodding her head that she was relaxed. At this point the image of descending

in a lift to her imagined safe place was introduced. Once Eve indicated she

was in her safe place, the visualization exercise of the sun was employed as

119

in the previous session. On completion of the exercise, Eve was requested to

present the following suggestion to herself: that during the coming week,

whenever the pain was particularly bothersome, she would at any time be

able to use this image of the sun during self-hypnosis. Eve was then asked to

imagine ascending in the elevator and instructed to open her eyes in her own

time.

Eve was instructed to practice "self-hypnosis" every day, incorporating the

suggestion given to her.


home.


The session began with Eve completing the BPI for the fifth time (see figure

4.33 and 4.34).

10

6+--=~~------~

4+-----~~4---~

2+-------------~

0+-~~--~~~~

~Pain at worst

L__ __ __j

Figure 4.33 Fifth completion of the BPI by Eve: Pain at worst rating

120

1 0 ""F"~""·"~"''"""'""'"'""-"'"""'"'"'"'"·"-'

8+------------l

6+------------j

4 +e .... c=-:-:-.......,...r:--------l

2 +-----==::"W!---2-A-1 0 +-,-.-...,..--...,..---r--1

·0~·0~·0~·0~·0~ ~ ~ ~ ~ ~

~0 ~0 ~0 ~0 ~0 0~ 0~ 0~ 0~ 0~

)5..G::..CJ,.G G G

"Cj rv<::-v O:J'v ~ <t:J..;s

Figure 4.34 Fifth completion of the BPI by Eve: Pain Interference score

Eve's Pain Right Now rating had dropped to a rating of one, as opposed to the

original rating of six. Eve stated that this was because she felt relaxed in

anticipation of the session. Eve reported that she had practiced successfully

and that she was feeling "more relaxed in general". She noted that someone

at work had commented that she looked years younger.

Eve again "hypnotized herself' in the researcher's presence and used the sun

visualization exercise. She was complimented on the ease with which she had

learnt to hypnotize herself and instructed to persist with her self-hypnosis

exercises, which would increase her ability to relax more quickly and deeply.


home.

121


The session began with Eve completing the BPI for the sixth time (see figure

4.35 and 4.36). Eve's Pain Interference score had dropped, mostly due to her

rating for Interference with Sleep dropping from an eight on the first

completion to a rating of four on this completion.

10

8+---------l 6-t----""-..:c--,.--------j

4-t-------"~:+---------r--l

2+-----------"'~

0-t--r---r-.,..---r--,---l

-4-Pain at worst

Figure 4.35 Sixth completion of the BPI by Eve: Pain at worst rating

1 0 .. ----"-~---····-···-* 8 +--------!

6 +--.--------!

4 ~-r-='--"'--7'-i!:-;..--.----:-::::l

2 -+---=---::::~ ... ..-~ 0 -t-....,.-.....,---,-........,.--,.--j

-4-Average of interference items

Figure 4.36 Sixth completion of the BPI by Eve: Pain Interference Score

Eve stated that her practicing went well. Eve hypnotized herself as in the

previous session. She stated afterwards that the "self-hypnosis" was having a

positive impact on her whole life because she felt more relaxed. I commented

that it was a skill that could be used whenever needed and complimented her

122

on her inner strength and determination, which would ensure that she coped

with the pain in the future.

It was agreed that this be our last hypnosis session. A feedback session was

scheduled for two weeks time with Eve and her husband in their home.

Feedback session

Eve reported still "feeling wonderful" and said she owed it all to her "self

hypnosis". Eve stated that she had just been promoted at work and felt

confident that she would cope because her back was "feeling great". Her

husband agreed with her work colleague that Eve was "looking great". He said

he appreciated no longer being roped in to rub her back and instead having

that time to do something pleasant together.

Meta perspective

From an ecosystemic viewpoint, it was necessary to create a hypnotic

experience that would be congruent with Eve's expectations and fit with these,

rather than forcing her experience into a pre-conceived framework. For

example she believed that the "deeper" one went, the more powerful hypnosis

would be. Therefore, arm levitation was used to prove to her how "deeply she

was hypnotized". The image of going down in a lift was also used in response

to her request for depth. Although from an ecosystemic perspective no

credence is given to reified concepts such as "depth" of hypnosis, this term

was used because it linked with the conceptions of the client. As Fourie

(1991a, p.475) states, an "implication of an ecosystemic approach to

123

hypnosis, and one following from the idea that it is possible to capitalize on

peoples' conceptions of hypnosis, is that the language of operation often

differs from the language of conception".

The consensual domain within which we were situated appeared to adhere to

the ideas that hypnosis could help with relaxation and that hypnosis involved

imagery and visualization. Relaxation did play an important part in these

sessions because Eve's pain appears to be related to muscle spasm. Turner

and Chapman (1982) state that relaxation's primary purpose is to relax tense

muscles believed to cause musculoskeletal pain. The idea that hypnosis

involves visualization was capitalized on through the use of the metaphor of

the sun. Eve's pain was likened to the sun because burning is the primary

sensation she associated with her pain.

Eve had not expected the pain to disappear, but wanted to be able to cope

with it. The researcher, therefore, linked with the idea that hypnosis made her

feel unusual and suggested that this unusual feeling evoked by the hypnosis

might be easier to cope with than the pain.

With regard to the BPI, Eve's Pain at Worst rating had dropped from a seven

on the first completion to a two on the final completion. Her Pain Interference

score had dropped to a 1. 7 on the final completion of the BPI, as opposed to

her score of four on the first completion.

124

4.4 MIKE

Mike, his wife (Kate) and their son and daughter attended the first session,

held in their home on a Thursday evening. Mike had already had three lower

back operations, the last of them five months before the first session. He

stated that he still experienced pain on a daily basis.

Mike had been back at work for two months. Mike was in the construction

industry and found it difficult to confine himself to just supervising his men. His

doctor recommended that, if he was going to insist on still being active on site,

he should work half-day for a few months so as to allow his back to heal

completely from the surgery. Mike felt very frustrated by this and stated he

hated "hanging around the house like a spare part." He admitted that he was

very irritable and impatient with his wife and children because he found it hard

to explain how he was feeling: "how could they understand anyway".

Mike's wife, Kate, was angry that he had been through so many operations

and felt the medical profession had failed to help him effectively. She admitted

she found Mike difficult to deal with and very demanding. Mike's son said that

Mike always been very approachable, but now he felt like he had lost his

father's friendship. Mike's daughter agreed and said they now went to Kate

with all their problems. The children found him unreasonable, impatient and

difficult to please.

125

MMFF Assessment




Roles

Mike's occupational role had been affected as he was only working half-day at

the time of the sessions, and Kate had become for the moment the primary

breadwinner. As he subscribed to fairly traditional views on masculine roles,

he battled to accept this change in role. Mike compensated by being

dictatorial with his wife and children. Kate had taken on the major share of

responsibility in running the family, including listening to the children's

concerns, shopping, and mediating between her husband and children.

With regard to affective roles, Mike no longer provided nurturance or support

for his wife or kids. Mike was moody most of the time and had lost interest in

their sexual relationship. Kate stated that she still cared deeply for him but

was "afraid of touching him". Kate believed that Mike was no longer

supporting her emotionally and felt she was not always able to respond to the

increased demands of her children for love and attention.

Communication

As Mike became increasingly absorbed in the frustration of his pain problem,

he manifested many of the characteristics of chronic pain patients, such as

anger and irritability. The children felt that when he did speak it was usually to

126

express frustration, anger or criticism, directed mainly at them. As a result, the

children found it difficult to talk to him and no longer went to him for help and

advice. Kate was angry with him for not keeping up his end of responsibility,

but she did not express her anger. Her silence led to a sense of resentment

mixed with hopelessness. Silence and an avoidance of emotional issues

appeared to be the main features of this family's style of communication.


Kate attempted to maintain an empathic involvement with the children, but

there appeared be to a lack of involvement between Mike and Kate. They no

longer had sexual contact, and had very little positive communication. There

also appeared to be a lack of positive involvement between the children and

Mike.

This family appeared to be characterized by the members feeling a lack of

understanding and support. Kate and the children felt that Mike did not

understand how they felt and Mike complained of the same thing.


Mike expressed a lot of emergency emotions. The family withdrew from him

and found it hard to express concern and caring because of his outbursts of

anger and frustration. The only welfare feelings expressed were between Kate

and the children. Kate felt sorry for the children. She stated that she felt sorry

for Mike, but also angry with him. She felt it was pointless to for Mike to say

127

that no one understood how he felt when he made it so difficult to talk to him

about it.

Problem solving

Mike was aware that the quality of his relationships with other members of the

family had suffered a decline following the onset of his pain problem. He was

ready to accept that the pain problem was not only his personal problem, but

also a family problem, because of the deterioration in the way family members

normally interacted with each other. At this stage, however, the problem

solving process had not moved past the identification phase.

Behaviour control

This family appeared to be characterized by chaotic behaviour control,

because rules did not remain consistent and were subject to repeated

change. As he was no longer the primary breadwinner, Mike's self esteem

had suffered a blow. He no longer held the same position of power in the

household and he appeared to compensate by making unreasonable

demands on the children and being overly strict. At other times he would feel

guilty about his outbursts and then let them do what they liked. Kate tried to

maintain order in the house, but this was made difficult by Mike's

unpredictability. She stated that at times the way she did things was accepted,

but at other times he would openly contradict her.

128

The remainder of the second session was used to discuss the family's

expectations of hypnosis and to allow Mike to complete the BPI for the first

time.

Expectations of Hypnosis

Mike believed that hypnosis might help him gain some form of control over his

pain so that he would not be so irritable. He hoped that it would "calm him

down" somehow so that he wouldn't be "so short-fused" with his family. Kate

agreed that she would like it to help him relax so that it would be easier for all

of them to be around him.


Mike completed the BPI for the first time (see figure 4.37 and 4.38).

1 0 M~-·--·-·----···~---~-----8 -8 -6 -e-Painat 4 worst 2 +-----------!

0+--..,----r-,......-....,----r---1

Figure 4.37 First completion of the BPI by Mike: Pain at worst rating

129

1 ~ -"'~--,~~-·-··-·--l r--------, 6 • r .4 ! ..._Average of

interference 4 +-----------! items 2 +--------l L__ ____ _J

Figure 4.38 First completion of the BPI by Mike: Pain Interference score

Mike reported that he used analgesics even though they had a negligible

effect on the pain. He also took sleeping tablets to help him cope, because by

sleeping at night he felt he could get through the day.

BE?fore scheduling the next session, a reframe of the family's interaction with

Mike was introduced. It was suggested that perhaps they were not intolerant

of him, but rather frustrated that he was no longer the person they knew. I

suggested that perhaps they were just as frustrated as he was: frustrated by

what pain had done to him and frustrated by their inability to help him

overcome pain. All members of the family readily accepted this reframe. The

third session (first hypnosis session) was scheduled for the following

Thursday evening in their home, with Mike and Kate to attend.

130

First Hypnosis Session

The session began with Mike completing the BPI for the second time (see


1 0 ·--~-·-,-----· .. -·-·----~~-.-8 ...a.-8

6 +----------1 -..Pain at 4 worst

2+----------1 0+--,---.,.-.,..-....,-.........,.----l

Figure 4.39 Second completion of the BPI by Mike: Pain at worst rating

10 8

6 4

2 0

7.4 ...... 7.3

! •

i

-..Average of interference items

Figure 4.40 Second completion of the BPI by Mike: Pain Interference score

A suggestion was made to the couple at this stage that, as they were both

feeling a lack of understanding and support, hypnosis could be used to help

them get in touch with themselves and their needs. I commented that this

could also help them communicate their needs to each other. It was

131

suggested that closeness, breathing together and hypnosis could also

become associated with less pain.

Mike and Kate set up two chairs facing each other. They made themselves

comfortable and I asked them whether they would prefer to go into hypnosis

with their eyes open or closed. They both elected to close their eyes and did

so at this stage. I began to speak softly to them, asking them to breathe

slowly and deeply, and then took them through a joint guided relaxation

exercise. The pair was then asked to imagine a staircase consisting of ten

stairs and to imagine descending those stairs, each in their own time and

each to a place they felt safe and comfortable in. Once they had reached their

imagined safe place, they were asked to "take in the place with all their

senses" and then to ascend the stairs again, when each felt ready, and open

their eyes.

Mike described the experience as very relaxing and peaceful and Kate agreed

with this. Mike stated that he had felt "more connected" to Kate than he had

"in a long time". For homework Mike was instructed to relax himself, with Kate

assisting in the process by speaking in a soft tone of voice and by directing

his attention to relaxing each group of muscles in turn. Once Mike indicated to

Kate that he was relaxed by nodding his head, she was to instruct him to

descend the imaginary stairs to his "safe place".

132

In addition the couple was instructed to set aside 15 minutes a day after

supper, as a family, to talk about good things. The next session was

scheduled for the following Thursday in their home.


The session began with Mike completing the BPI for the third time (see figure

4.41 and 4.42).

10 -·-----·---·,·~--

8~~8--~8--~----~ 7

6+-------------~

4 -1-----------------1

2+-------------~

0-+--..---r-.,.............,.---,...--!

-e-Pain at worst

L__ __ __j

Figure 4.41 Third completion of the BPI by Mike: Pain at worst rating

1 0 -.---·----·-··--·~~ 8 +-:::-+o4~>--,------4

6 +---------i

4 +--------1

2+-------1

0 -t-.,.--...,-...,-...,.........,..--j

..-------------e-Average of

interference items

Figure 4.42 Third completion of the BPI by Mike: Pain Interference score

133

The average for the Interference items was lower on this completion, mainly

because the rating for Interference with Relations with Other People had

dropped. Mike attributed this to making time to spend "positive time" together

as a family: "we actually laughed together about something". He stated that

his rating for Interference with Mood had not improved, however, as they had

found practicing to be frustrating. The couple reported that they had problems

achieving the same degree of relaxation, and that Mike had found it difficult to

go to his imagined safe place. They had felt separated and not connected like

during the previous session. They asked for guidance on how to practice

more effectively.

I suggested that perhaps they needed some physical connection to help them.

The couple was instructed to sit next to each other on the couch and hold

hands.

The couple made themselves comfortable and closed their eyes. They were

guided through a joint relaxation exercise and it was then suggested that they

create a third special place together by building on each other's images. Mike

introduced the initial image of walking through long grass in the sun. Kate said

that reminded her of a weekend a few years back when she and Mike went

away to the mountains. The two of them built up an image of walking in the

mountains together. Once the couple agreed their safe place was "real" to

them and "fixed in their minds", they were instructed to open their eyes in their

own time.

134

For homework, the couple was instructed to continue practising. In addition

the couple were instructed to go out on a "date" in the coming week. It was

suggested that if pain didn't stop Mike going to work, it should not stop him

taking part in social activities with his wife or children.

The next session was scheduled for the following Thursday in their home.


The session began with Mike completing the BPI for the fourth time (see

figure 4.43 and 4.44). Mike's Pain Interference score was lower, as the rating

for Interference with Mood had dropped from a seven the previous week to a

four on this completion. His rating for Interference with Enjoyment of Life had

dropped from a seven the previous week, to a five on this completion.

10

8~--~~,-----~L_----~ 6 +--------""'~---!

4+--------~~--~

2 +--------------4

0+--....-.,.---,.--,..----r---i

Figure 4.43 Fourth completion of the BPI by Mike: Pain at worst rating

135

10~~--·-~---~-~·~~~

8+-::----.----.----.....---.-------------1 r--'----------,

6+--· --"""oi,&--1~---4 -e-Average of interference items

4 +----------1

2+------------=r-------~

0+--r---r-..---.----,----!

Figure 4.44 Fourth completion ofthe BPI by Mike: Pain Interference score

Mike reported that he and his wife had carried out their homework assignment

by going out for lunch. They had both enjoyed it, particularly Kate who said

that for the first time in ages she felt like Mike's partner instead of his mother.

Mike had also started to help out more by collecting the children from school.

He stated it gave him "a reason to leave work" rather than "forcing" himself to

leave in the afternoon.

The couple reported that their practicing had been more successful. They

found it quite easy to use their "mutual safe place" as Kate knew what it

looked like and could help create it for Mike. I suggested that the practice was

strengthening their connection and suggested that hypnosis was becoming

part of their relationship.

136

Kate was asked if she would be willing to hypnotize Mike, out of her

experience of the previous week and their practising at home. Kate agreed to

try and she and Mike made themselves comfortable on the couch. They

joined hands and both closed their eyes. Kate started to speak to Mike in a

soft voice, suggesting that he was feeling relaxed and peaceful. She asked

him to focus on his breathing and kept repeating words like "calm" and "quiet".

I commented on how they appeared to be breathing in time with each other,

and suggested that perhaps this was because of their connection.

Kate then directed his attention to relaxing each group of muscles in turn.

When Mike indicated to her verbally that he was totally relaxed, Kate called up

the image of the staircase and instructed him to go to their imagined safe

place. Once both indicated that they had reached this imagined place, they

were asked to concentrate on the connection between them. I suggested to

them that this connection could make it easier for them to understand each

other and know what the other was thinking and commented that it might even

be possible for Kate to use this connection to take some of Mike's pain away.

Mike was now asked to become aware of any pain present in his lower back.

Mike then was asked to imagine a control room in his head filled with a

number of machines, each controlling certain processes in his body. It was

suggested to Mike that, as he was a man who worked with machinery on a

daily basis, it would not be too difficult for him to recognize the machine that

controlled the flow of pain in his body. I asked Mike to indicate to me when he

had found this imagined machine. Mike was then asked to notice that the

137

machine had a dial on it that enabled the pain to be turned up or down. Mike

was asked to imagine reaching out and turning the dial ever so slightly to the

right, so that the pain in his lower back became slightly worse. Mike indicated

when this had happened. Mike was then asked to imagine turning that same

dial to the left and feeling a corresponding decrease in pain. He was

instructed to imagine turning the dial down as far as he could get it to go. It

was suggested that Mike draw on the strength provided by his connection to

Kate to help him achieve this. At this, Mike visibly held her hand tighter.

On completion of the exercise, Mike was requested to present the following

suggestion to himself: that during the coming week, whenever the pain was

particularly bothersome, he would at any time be able to use this image of the

dial during self-hypnosis. Mike and Kate were then asked to imagine

ascending the staircase and instructed to open their eyes in their own time,

stressing that the connection that had been established would not be lost.

Mike reported that his pain had definitely diminished and that he "could feel

Kate helping". He stated that he felt very connected to her and felt "a wave of

support and understanding from her".

Mike was instructed to practice "self-hypnosis" every day, incorporating the

suggestion given to him. In addition, it was suggested that a family outing be

planned for the coming week.

138

The next session was scheduled for the following Thursday in their home with

Mike and Kate to attend.


The session began with Mike completing the BPI for the fifth time (see figure

4.45 and 4.46).

10~------~-·----~---~ 8-Hit--..... :---=-----j

6+------""'1~-------..,--------i

4+---------i

2+---------i

0+--..--.---,--.....-....---i

-e-Pain at worst

Figure 4.45 Fifth completion of the BPI by Mike: Pain at worst rating

1 0 ·-------·----·--·-----·--··-·---····

8 +L~~~~~------~

6 +-----"""""...--------~ -e-Average of 5 interference

4 +------------~ items

2+------------i

0+---r-...,..------r--r---r----1

Figure 4.46 Fifth completion of the BPI by Mike: Pain Interference score

139

..

Mike stated that the family had gone to the drive-in on the weekend, as Mike

could not sit through a whole movie. They had taken blankets along and had a

"huge picnic" on the ground next to the car. Mike said he had stopped seeing

his enforced time at home as "a punishment", but rather as time to spend with

his family before he was "back at it till all hours".

Mike had experimented with the image of the control dial. He said the

exercise was most effective when holding Kate's hands as could "draw

strength from her". He felt a very deep connection to her when practicing. I

suggested that this type of connection could be strengthened even more, and

that the more they practiced the more the connection would be strengthened,

even when they were not hypnotized.

Mike was asked to relax himself in the presence of the researcher by closing

his eyes, focusing on his breathing and allowing a sense of heaviness to

develop throughout his body. He then used the dial visualization exercise.

Mike was complimented on the ease with which he had learnt to hypnotize

himself and instructed to persist with his self-hypnosis exercises. I

commented on how well they are doing without me, and encouraged them to

experiment more. The next session was scheduled for the following Thursday.


The session began with Mike completing the BPI for the sixth time (see figure

4.47 and 4.48).

140

1 0 -.-~--~-~--~------~---------~---------~ 8 8

8 T-11,... ..... :---,------;

6+----~~----o:.;-----!'--------, -e-Pain at

4 +--------"""H worst '--------'

2+-----------!

0+--.....-,..............,----,..-...,.----!

Figure 4.47 Sixth completion of the BPI by Mike: Pain at worst rating

1 0 --------···---·-· .. ---·-····

8

6 T----~~~-~

4 T-------~~ interference items

1----------'

2 +---------4

0 +-~--r-~~--...,.----!

Figure 4.48 Sixth completion of the BPI by Mike: Pain Interference score

Mike stated that his practicing went welL Mike hypnotized himself as in the

previous session. He stated afterwards that the "self-hypnosis" was having a

positive impact on their life as a family and that it had "helped us through a

difficult time". I commented that it was a skill that could be used whenever

needed and complimented both of them on their inner strength and

determination, which would ensure that they coped with the pain in the future.

141

It was agreed that this be our last hypnosis session. A feedback session was

scheduled for two weeks time with Mike and Kate in their home.

Feedback session

Mike reported "feeling good" and stated that he was going back to work in two

weeks. He stated that the hypnosis had worked for him because it focussed

his attention away from the pain and onto his wife. He felt it created a bond

between them and he felt a great deal more understanding from her. Mike

believed it helped their relationship through a difficult time. Kate stated she

was "just happy to have more of the old Mike back".

Meta perspective

From the MMFF assessment it was clear that Mike was experiencing a feeling

of lack of support. Mike felt that no one understood how he was feeling and

this opened up the therapeutic possibility that an experience of more support

would help him deal more effectively with his perception of pain. Kate wanted

to support him, but did not know how to approach him. Hypnosis could give

her a tool to do so.

From the start the hypnotic experience was designed to create a feeling of

increased closeness. The breathing homework created a context in which

Mike and his wife had to spend more time with one another. Joint guided

relaxation exercises were used and the couple created a combined image of a

142

safe place. The additional exercises were also designed to ensure that the

couple and family spent positive time together.

The image of a control dial joined with Mike's idea that he would like to use

hypnosis to control his pain. The image appeared to be effective because

Mike worked with machinery and could relate to the idea of a mechanism

controlling things.

With regard to the BPI, Mike's Pain at Worst rating had dropped from a rating

of eight on the first completion to a four on the final completion. His Pain

Interference score had dropped from an initial 7.4 to 4.4. Mike still rated

Interference with Sleep as a ten and Interference with Normal Work as an

eight on the final completion, as he was still at that stage confined to working

half-day.

4.5 NICK

Nick and his wife, Pam, attended our first session, held in their home on a

Tuesday evening. The couple's daughter was only three years old and it was

decided not to include her in the session. Nick had a spinal fusion two years

prior to the time of these sessions, but had been left with some permanent

nerve damage, which caused him to continue to feel some pain in his lower

back as well as referred pain in his right leg. He stated that he tried not to let

the pain interfere with his life. His approach was to have "as many weapons in

my arsenal as possible". A year prior to these sessions he had been on an

exercise course designed for patients with chronic back pain and he

143

religiously stuck to the routine that had been worked out for him. He felt he

had a neurosurgeon and physiotherapist that he trusted and he referred to his

exercise routine, doctor and physiotherapist as his "team".

MMFF Assessment




Roles

At the time of these sessions, Nick's occupational role was unaffected and he

remained the primary provider. Nick very rarely missed work because of his

pain problem.

Nick was still an active participant in all aspects of family life. He and wife still

shared responsibility for family budgeting, shopping and even cooking. Even

"on a bad day", Nick still took an active interest in his daughter.

Affective roles had also been little affected. The couple appeared to be very

nurturing and supportive of each other. The marital relationship appeared to

be characterized by love and affection, give and take, and much caring for

each other.

144

Communication

This family did not appear to demonstrate any problems related to

communication. Pam appeared to engage in supportive and encouraging

communication, rather than pain-reinforcing messages. She had a matter-of

fact attitude to his illness and Nick was equally determined to get over his pain

problem. Given that match it is not surprising that this couple engaged in

direct and clear communication. In spite of the pain, they retained their stance

of sharing their negative and positive thoughts and feelings with each other.


This family appeared to demonstrate empathic involvement. They appeared to

have a true affective concern for each other and had the ability to take an

interest in each other's pursuits, even if those pursuits were not of interest to

them personally. Both parents were very involved in the daughter's upbringing

and showed an equal concern for her well-being.


Neither spouse appeared to hold back on their welfare or emergency

emotions. Both believed that they expressed their "true feelings" towards each

other and "felt the freedom to do so".

Problem solving

Nick and Pam stated that they did not avoid disputes or arguments. They tried

to make all major decisions together and tried to resolve differences through

145

discussion. They also tried to always be open to seeing the other's point of

view.

The concern and affection they had for each other was evident in their

problem solving. They mentioned that Mike had recently been offered an

opportunity to relocate. This problem had involved thorough discussion and

they had to look at the situation from all angles, even their daughter's.

Although the offer was a good one for Nick and he was the primary

breadwinner, other factors "swung their decision". Pam was particularly happy

in her present job and they were living close to both sets of their daughter's

grandparents. As a result, they decided to stay where they were.

Behavior control

This family appeared to demonstrate flexible behaviour control, which,

according to Epstein and Bishop (1981), is the most desirable form of

behaviour control. Family rules were clear, but the couple had the flexibility to

modify family rules and, at times, even change them depending on what the

situation demanded. Nick was involved in all aspects of family life and had an

intimate relationship with his family. His periodic withdrawal was almost

expected and predicted and Pam happily moved in to fill the vacuum. The

couple exhibited the capacity to pitch in for each other without much fuss and

was happy to move in and out of their respective roles. Pam had no problem

with taking over some of Nick's usual activities if he was in pain. Similarly,

when Pam was busy he would assume some of her tasks.

146

The remainder of the second session was used to discuss the family's

expectations of hypnosis and to allow Nick to complete the BPI for the first

time.


Nick made it clear at our first meeting that it was important for him to have as

many skills as possible to cope with the pain, and this is the reason he wanted

to try hypnosis. He tended to cope with pain by not thinking about it and by

focussing on something else. He stated that ignoring the pain sometimes

became tiring and he hoped that through hypnosis he could achieve some

type of control over the pain so that he didn't have to avoid it. Nick stated that

he was very interested in learning self-hypnosis because he believed that it

might be a skill to add to his "arsenal".


Nick completed the BPI for the first time (see figure 4.49 and 4.50). Nick's

Pain Interference score appeared consistent with Nick's reports of the limited

effect pain had on his life. Interference with Sleep did, however, obtain a

rating of ten.

147

4+-----------i .._Pain at

worst '-----------'

2+-----------i

0-r---,-.-..,..-..,...........,--.....--!

Figure 4.49 First completion of the BPI by Nick: Pain at worst rating

1 0 .--~·--------. 8+---------f 6+---------f 4 +----=.------i 2 • 3.1

0 +-..,...--r-........--r--,-'""'"'

.._Average of interference items

Figure 4.50 First completion of the BPI by Nick: Pain Interference score

Pain's overall influence over this family appeared to have been kept to a

minimum. Therefore, only Nick was scheduled to attend the third session (first

hypnosis session) to be held in their home the following Tuesday evening.


The session began with Nick completing the BPI for the second time (see


148

10

8

6

4

2

0

_6 --6 - ~

I ..,._Pain at

worst

Figure 4.51 Second completion of the BPI by Nick: Pain at worst rating

10

8

6

4

2

0

3.1 ...-3.1

...._Average of interference items

Figure 4.52 Second completion of the BPI by Nick: Pain Interference score

Nick was asked to make himself comfortable and to concentrate on his

breathing. I suggested that his eyes appeared to be getting heavier and, at

this stage, he closed them. It was suggested that he should "become unaware

of the chair" he was sitting on and allow himself to become more and more

relaxed. I pointed out that his head was moving slightly and commented that

149

maybe his head felt heavy. His head then dropped slowly. I pointed out that

his arms might begin to feel heavy too. After a few moments, I picked his right

arm up and commented on how heavy it felt.

Nick was asked to imagine a staircase and to imagine descending the

staircase to a place he imagined to be safe and comforting. Nick indicated by

nodding his head that he had reached this imagined place. I commented on

how relaxed he appeared to be and asked him to focus and to notice the

details of how he felt at that moment and to be very aware of what it was like

to be in this state. He was instructed to try and find a name or word that

applied to how he was feeling at that moment. I asked him to raise his right

index finger when he had found a name and felt ready to come out of trance.

His breathing became lighter and quicker and that appeared to be an

indication that he was ready to come out. I suggested that he walk back up

the stairs and that when he reached the top he should open his eyes in his

own time. He was asked to remember the name he had given to what he felt,

so that we would be able to evoke that feeling again in his body.

The next session with Nick was scheduled for the following Tuesday evening

in their home.


The session began with Nick completing the BPI for the third time (see figure

4.53 and 4.54).

150

1 0 -~··-~·~-·-·-"----··~,~-""'

8+---------------~ 6 .. 6 __ 6

~5 4 +-------------~

2 +--------------~

0 -t--.......,.---,-"'"'T"""'"'--r-r---4

-e-Painat worst

L__ __ __j

Figure 4.53 Third completion of the BPI by Nick: Pain at worst rating

10

8

6

4

2

0

3.1 3_1

• • •3


Figure 4.54 Third completion of the BPI by Nick: Pain Interference score

Nick spoke about his experience of the previous week. He stated that he had

felt very relaxed and "very removed". He had named what he was feeling

"release". Nick said it felt strange to let go, but he also felt "relieved".

Nick was instructed to make himself comfortable. He was then asked to relax

himself by closing his eyes, focusing on his breathing and allowing a sense of

heaviness to develop throughout his body. He was told that "at the

151

appropriate moment" he would be aided in extending the relaxation into

hypnosis.

Once Nick indicated that he was relaxed, he was instructed to use the name

he had found during the hypnosis the week before to "go to his special place".

Once Nick indicated he has reached this imagined place he was instructed to

focus his attention on his lower back. Nick was asked to become very aware

of any pain present in his back and to focus his attention on it, instead of away

from it as he usually did. I suggested that Nick "give the pain a colour" so that

it would be "easier to focus on it". Nick stated that the pain was red.

I commented to Nick that he was aware that pain could move in your body, as

a lot of the pain he suffered was referred pain in his leg. I commented that

maybe we could use the "fact" that pain could move to his benefit. Nick was

asked to imagine the pain in his back starting to move and to visualize the

redness start to move up along his spine, carrying all the pain with it. Nick was

asked to visualize the pain moving up his spine, into his right shoulder and

then down his right arm. He was asked to visualize the pain flowing into his

right hand and, as it did so, to physically form a fist around it. Nick was asked

to imagine gathering all the pain into that hand and to "hold it tight".

Once Nick indicated that he had "collected all the pain" in his right fist, he was

instructed to open the fist and visualize all the redness flowing out of the

hand, carrying the pain with it.

152

On completion of the exercise, Nick was requested to present the following

suggestion to himself: that during the coming week, whenever the pain was

particularly bothersome, he would at any time be able to use this image of the

clenched fist during self-hypnosis. Nick was then asked to open his eyes in

his own time.

Nick's breathing became shallower and he opened his eyes. He was

instructed just to sit quietly for a moment and notice how he felt different. He

stated that his major feeling was again one of release and relief.

Nick was instructed to work on his breathing, going to his imagined safe place

by using "his word" and the clenched fist exercise at home. He was instructed

to notice through the week how he felt different and how the pain felt different.


in their home.


The session began with Nick completing the BPI for the fourth time (see figure

4.55 and 4.56).

153

8 +---------------

6 ~-.. 6-...~.,6io=--.::::--------'--e---P-a-in_a__,t I 4 ~A worst -2+-------------l 0+----...,---.,...-.,....--.,--...----!

Figure 4.55 Fourth completion of the BPI by Nick: Pain at worst rating

10 --"·-----···-~·~·---~-~--

8 +-----------1

6 +----------~ 4 +--"3'--'-. 1-'----<~;;}-..-+-' 13==---------l

• • • • 2.9 2+---------------1

I 0 -t-----,---,-----,.--,------,--1

-e-Average of interference items

Figure 4.56 Fourth completion of the BPI by Nick: Pain Interference score

Nick reported that the practicing had been very successful and that he was

sleeping slightly better due to his practicing just before going to bed at night.

He experienced the same feeling of release each time he practiced. He stated

that it was a different feeling for him as the feeling he normally associated with

the pain was one of fighting it off and keeping it at bay. He felt he could now

rather face it and release it. This left him feeling calm instead of tired.

154

Nick "hypnotized himself" as in the previous session and used the clenched

fist exercise. He was complimented on the ease with which he had learnt to

hypnotize himself and instructed to persist with his self-hypnosis exercises,

which would increase his ability to relax more quickly and deeply.


in their home.


The session began with Nick completing the BPI for the fifth time (see figure

4.57 and 4.58). He stated that he had one particularly good day when he had

experienced almost no pain. The average for the Interference items was lower

due to Interference with Sleep dropping from a ten on the first completion to a

rating of six on this completion.

1 0 --·-·-~·--·-·----····---~ .. --··--·-··· 8 +----------1

6 ~.,._.....,,-------_,~----j 4 +-----"""''k:----...---1

2 +----------1

0 +-'"""T"'---,r---,----r-r--1

..... Pain at worst

Figure 4.57 Fifth completion of the BPI by Nick: Pain at worst rating

155

10

8

6

4 3.1 3.1 ~

• • • 2

0

I i I

2.9 -1 • ..... 2.4 I

I

...,_Average of interference items

Figure 4.58 Fifth completion of the BPI by Nick: Pain Interference score

Nick hypnotized himself as in the previous session. I commented afterwards

that "self-hypnosis" was a skill that he could use whenever he needed and

complimented him on his inner strength and determination, which would

ensure that he continued to cope with the pain in the future. It was agreed that

this be our last hypnosis session. A feedback session was scheduled for two

weeks time with Nick in their home.

Feedback session

Nick reported that he was still practicing daily. He stated he had become as

addicted to "self-hypnosis" as he was to his exercise routine. He felt that "self-

hypnosis" was a worthy skill to have "in his arsenal" and that it had definitely

become part of his "team".

Meta perspective

From an ecosystemic viewpoint, it was necessary to create a hypnotic

experience that would be congruent with Nick's expectations and fit with

156

these. In this context, breathing and eye closure seemed to be agreed to be

appropriate induction behaviors and served as a punctuating ritual. In the

same way a return to natural breathing and opened eyes seemed to serve as

a waking-up ritual. The post-hypnotic discussions about the hypnotic

experience further served to confirm the experience as hypnotic.

Nick's interest in hypnosis was to acquire a skill and, therefore, the sessions

concentrated on "teaching him" the skill of "self-hypnosis". Nick also wanted to

be able to face his pain, instead of avoiding it. He, therefore, needed to focus

on and become aware of any pain present in his body and then "do"

something about it. In the first hypnosis session, Nick associated the word

"release" with what he was feeling. This opened up the therapeutic possibility

of introducing an image to help him "release" the pain. As a result, the

clenched fist exercise was used, and proved to be very effective.

With regard to the BPI, Nick's Pain at Worst rating had dropped from a six on

the first completion to a three on the final completion. His Pain Interference

score had dropped from a 3.1 to a 2.4.

4.6 HANNES

Hannes had been suffering from lower back pain for just over seven months

at the time of the first session. His neurosurgeon was unable to find a definite

cause for the pain and was advocating conservative treatment, which included

a week in hospital for traction. Hannes expressed anger at the doctor and felt

he was "not taking my problem seriously enough" and that the doctor was "not

157

doing enough". Hannes's primary treatment at the time of the first session

consisted of medication and physiotherapy. Hannes admitted in the first

phone call that was only "doing this" because his wife felt he was "doing

nothing to get well".

Hannes and his wife, Elize, attended the first session held in their home on a

Wednesday evening. Although the whole family had been requested to attend

the first session, Hannes stated he didn't see why their teenage son had to be

there, as his pain had "nothing to do with him".

MMFF Assessment


areas. The MMFF was started during the first session and completed the

following Wednesday evening in the second session.

Roles

Hannes's occupational role had not been affected beyond the week he spent

in hospital in traction. What was problematic was that he would go to work,

but then arrive home and withdraw and engage in protective behaviouL He

complained that he was "too sore" to do anything in house, or go shopping, or

take his son anywhere.

With regard to life skills development, Hannes appeared to have lost interest

in his son and his son's education. Elize appeared to carry the major

158

responsibility for their son, with Hannes appearing to only step in when she

insisted upon it, and then without enthusiasm.

With regard to affective roles, Hannes appeared to have withdrawn from

family life. Elize complained that he was "extremely distant" and hardly ever

spoke to her or their son anymore. Hannes had taken to sleeping in the spare

bedroom when his back was sore and Elize felt he had lost all interest in their

intimate life. She stated that she found it disturbing that he seemed to have

so little interest in their welfare. Hannes did not seem perturbed by this

statement and made no effort to contradict it.

This family appeared to be characterized by a major shifting of responsibilities

from the husband to the wife. Hannes was so preoccupied by his own

misfortune that he has seemed incapable of fulfilling any affective function in

the family. Elize appeared to be finding it difficult to respond to the increased

demands of her son for love and attention.

Communication

Elize had already stated that Hannes had all but stopped speaking to her and

their son. As Hannes had withdrawn so much, she and her son had also

stopped making the effort to speak to him. Elize stated that she felt like she

was speaking "at" Hannes, instead of "to" him, and that it was like "one-way

communication".

159

Elize found herself in the situation of wondering whether Hannes was sick or

not. The doctor was unable to find a definite cause for the pain and he was

always well enough to go to work, but not well enough to do anything at

home. Her doubts were, however, never verbalized and she felt guilty about

even having such doubts. Elize also did not express her anger at having to

take over so many responsibilities from Hannes. She appeared to live in silent

resentment toward Hannes.

Prior to this session no discussion about Hannes's back pain and its negative

consequences on their relationship had taken place. Hannes spoke little

during the completion of the MMFF and it was Elize who answered most of

the questions. Elize appeared to enjoy being able to express how she felt and

the difficulties they were encountering.


The relationship between Hannes and his family appeared to be characterized

by an absence of involvement. Hannes continued to be the primary provider,

but other than that appeared to only eat and sleep in the house, often in a

separate room to Elize.


Elize found it difficult to express caring or concern for Hannes because he

"shut himself off' from her. She also felt that he demonstrated little affection

and concern for her. Elize stated that she felt "pushed away" and had taken to

"keeping her distance" from him.

160

Problem solving

Although this family appeared to be experiencing problems in the instrumental

and affective areas, Hannes blamed all his current problems on the pain. He

felt that "everything would be better at home if the pain could be taken away".

Roy (1984) states that this attitude acts as a deterrent against the family's

willingness to engage in therapy, because the patient insists that if the pain

could be removed, the family problems would evaporate. Such patients deny

family problems, yet the continuing and unresolved difficulties in the families

of such patients are evident.

Hannes appeared to be firmly entrenched in the sick role and was no longer

involved in the decision-making process. The onus of problem solving

appeared to rest squarely on Elize's shoulders. Elize found herself forced into

making an increasing number of decisions, without the benefit of his counsel

and without him seemingly caring one way or another.

Behaviour control

This family appeared to demonstrate chaotic behaviour control with family

rules subject to change. Elize tried her best to maintain order in the

household, with no support from Hannes. She realized that at times she was

overly strict with their son, but at other times she felt sorry for him and was

overly indulgent with him.

161

The remainder of the second session was used to discuss the couple's

expectations of hypnosis and to allow Hannes to complete the BPI for the first

time.


Hannes stated that he wasn't sure hypnosis could do anything for him and

repeated that he was attempting hypnosis to "make Elize happy". If anything,

he hoped that it would "take the pain away".


Hannes completed the BPI for the first time (see figure 4.59 and 4.60).

10 r---~·--· ·-·--8 e7 6+-----~--------4

4+-------------~

2+-------------~

0+--r~--~~~~

-e-Painat worst

Figure 4.59 First completion of the BPI by Hannes: Pain at worst rating

162

10 8 6 4 2

• 4.6

0

·0<::-0-.::s

?f 0~

'!<..G ,.....~

! -e-Averageof

interference items

Figure 4.60 First completion of the BPI by Hannes: Pain Interference score

The third session (first hypnosis session) was scheduled for the following

Wednesday with Hannes and Elize. However, on the Monday morning,

Hannes opted to withdraw from the study. He stated that he had not enjoyed

the first two sessions and said: "I don't see what my back pain has to do with

any other difficulties I may be experiencing in my life." Hannes stated that he

had decided that hypnosis might not be an "appropriate" form of treatment for

him.

This case study was retained as it illustrates one of the possible problems

identified in the research design stage, namely the possibility that the chronic

pain sufferer would be unwilling to see the need for a psychological solution.

Roy's 1989 study with 32 headache and backache patients, found that

backache sufferers in particular were less inclined to accept that their pain

problem could be linked to underlying psychological factors. Roy (1989)

believes that by defining these patients' pain problems in psychological terms

they may feel their problem is somehow being trivialised and not believed.

Hannes already felt the medical community was not taking his problem

163

seriously enough and possibly felt that a psychological solution would only

serve to confirm that his problem was not "real".

4. 7 CONCLUSION

The first five cases reported above represent a sample of what is possible in

ecosystemic hypnosis. The illustrations are presented not as "proof" of the

effectiveness of ecosystemic hypnotherapy, but simply to illustrate this way of

thinking and it's practical application in the treatment of chronic lower back

pain problems. It is conceivable that a more experienced therapist might have

conducted the therapy in different manner than that employed in the current

study and might have obtained different, although not necessarily better,

results. Although a feedback session was held, no claims can be made about

the permanence of the therapeutic gains achieved. However, barring a

sudden or dramatic relapse it would appear that an ecosystemically oriented

approach to chronic lower back pain might have a wider application.

The following and final chapter sets out the implications that follow from the

use of ecosystemic hypnosis as a treatment for chronic pain.

164

CHAPTERS

CONCLUSION

Capra (1983) states that to understand and deal effectively with pain it must

be viewed in its wider social context. The current study described the impact

of chronic low back pain on each participant and his/her family system. From

an ecosystemic perspective it is vital to examine how chronic pain is

embedded in each individual participant's total ecology and to consider the

possible meaning of and function served by each participant's pain before

embarking on treatment. The MMFF provided an ideal preliminary basis for

conducting an ecosystemic diagnosis of each subject's pain problem and it

appeared to be helpful to administer it in the subject's natural environment.

The Brief Pain Inventory proved invaluable for keeping track of treatment

progress.

A number of possible problems were identified in the research design stage.

The current study did not encounter any problems in getting the spouse of the

chronic pain sufferer to attend. However, the possibility that the chronic pain

sufferer would be unwilling to see the need for a psychological solution was

found in Hannes's case.

All case studies showed the importance of using an approach that fits best

with all involved. The current study attempted to take the context of each

participant into account, including the subject's attributions, expectations,

165

belief systems, life circumstances and relationships. This is one of the current

study's strengths. Had a quantitative approach been employed, individual's

attributions of meaning would either have been lost or would have assumed

statistical importance and the findings could have differed considerably from

those of the current study. The subjects would also not have had the

opportunity to make sense of their pain in their total circumstances.

In each case study the researcher spent time trying to understand the

conceptualisations of hypnosis, held by the subject and his/her family

member/s, as treatment had to fit with these conceptualisations. If the system

expected hypnosis to involve relaxation, then that idea was capitalised on.

Once hypnosis had been experienced, the researcher had to work with each

system's experience thereof so as to perturb the consensual domain around

pain.

The flexibility of the ecosystemic approach allows it to be compatible with

more conventional forms of treatment. It will be noted that many of the

techniques used in traditional hypnosis were employed in the presented case

studies, such as hand levitation, eye closure and imagery. However, the

thinking behind the use of these techniques represents the point of departure

from traditional hypnosis. For example, hypnosis was used in this study to

establish an experience of support, as in Dudu and Mike's case. Hypnosis

was also something that the spouse or a relative of the subject could do, as in

the case Dylan, Lindy and Kate, in order not to feel helpless or cut off. During

166

the entire process, the experiences of all individuals were incorporated into

the therapeutic rationale through the use of feedback.

The current study appeared to have a number of shortcomings. Firstly, due to

the limited sample size, no significant gender differences in the experience of

chronic low back pain could be discerned.

As this study emphasised unique and personal contextual factors and used a

descriptive, qualitative method, the study's second shortcoming is that the

findings cannot be "proved" or verified by future replication. However, from a

perspective that seeks to understand rather than prove, this is not considered

problematic.

A further limitation of qualitative research is that the human mind tends to

select data that fit with working hypotheses and initial impressions (Moon et

al., 1990). The implication of this is that the themes and meanings elucidated

by the researcher are not the only possible distinctions that could be made.

Hence the meanings that readers attribute to the case studies may well differ

from the researcher's meanings.

A further limitation of this study is that member checks were not conducted

formally (Lincoln & Guba, 1985). This means that the participants were not

provided with the research report to comment on. However, as meaning and

outcomes were continuously negotiated in the sessions, informal member

167

checks did occur and were believed to be adequate in a study of this limited

scope.

There exists an absence of published material documenting the use of

ecosystemic hypnosis for chronic pain patients and, therefore, the

acceptability of this approach is also a problem. The issue of acceptability is

also complicated by the lack of specific therapeutic techniques or a plan of

action, and there being no objective evaluation of treatment.

The current study appeared, however, also to have a number of strengths.

Firstly, the current study was not interested in the etiology of pain. As Capra

(1983) states, in practice it is frequently impossible to know which sources of

pain are physical and which psychological. The advantage of using an

ecosystemic approach is that it does not emphasize the origin of the subject's

pain. An ecosystemically oriented approach allows for the development of an

appropriate context wherein some degree of pain relief may be achieved

regardless of the origin of such pain.

Each subject's pain complaint was, therefore, regarded as "real" and

legitimate. This stance appeared to make it easier for the participants to talk

about their pain problems. In many cases it appeared that the researcher was

the first person to ever listen to a detailed account of the subject's pain in

terms of where it began, perceived causes and possible solutions, the

reactions of different family members to the problem, coping behaviours etc.

This in itself appeared to be therapeutic. Each patient's pain story needs to be

168

taken seriously and be explored thoroughly. An ecosystemic approach may

also capitalise on the client's ideas surrounding his/her pain. Information may

be forthcoming in areas such as the subject's interpretation of the presumed

cause and nature of his/her pain, possible reasons why he/she did not

respond to previous treatment, and his/her outlook on the future regarding the

pain problem.

A second strength of this study was that realistic treatment objectives were

set. The permanent relief of chronic pain symptoms is rarely reported in the

literature. In many cases, adjustment to continuing pain is a more attainable

treatment goal than pain alleviation (Spinhoven & Linssen, 1989). The

success of ecosystemic hypnosis in this study was not decided by its bringing

about complete and permanent pain relief for the chronic low back pain

sufferer. Ultimately, the effectiveness and viability of any ecosystemically

oriented therapy for the chronic pain syndrome is determined solely in terms

of whether or not it has facilitated the development of more functional patterns

of interaction and relationships in the participant's ecology. The feedback

sessions held with the families were important in this regard to gauge the

individual attributions made by each person who came into contact with the

research. Each participant needed to determine the relevance of the

experience for him or herself, rather than the relevance being predetermined

by a set of rigid research principles such as sample methods, data collection

methods etc.

169

A further advantage of an ecosystemic approach is the attempt to fit treatment

to the participant's ecology. No attempt was made in this study to impose a

treatment solution in a linear manner and no attempt was made to force the

participant's and his/her family's ideas into a particular conceptual framework.

The researcher attempted to link with the participant's ideas about him/herself

and about his/her specific problems. An ecosystemic approach to hypnosis is,

as far as is known, the only approach which actively aims at utilising the

family's attributions regarding hypnosis and no attributions are viewed as

misconceptions (Fourie, 1992). An ecosystemic approach recognizes only

conceptions and attempts to utilize these attributions in arriving at different

and acceptable ways of viewing the problem.

Many chronic low back pain patients run the gamut of conventional treatment

and are left frustrated because they have failed to respond to it. An advantage

of an ecosystemic approach is that some form of therapeutic change is

inevitable once more functional patterns of interaction have been initiated in

the subject's ecology. As a result, the subject could be spared some of the

costs and risks frequently associated with other forms of medical examination

and treatment.

170

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6,8-17.

Baker, R.A. (1990). They call it hypnosis. New York: Prometheus Books.

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186

APPENDIX A

Letter to Physiotherapists

Dear

I am presently conducting research for my Master's degree in Research

Psychology on chronic low back pain.

I am seeking patients who are suffering from chronic low back pain to take

part in this study. The proposed treatment consists essentially of

hypnotherapy and/or guided relaxation techniques. Treatment sessions will

consist of once-weekly meetings with the patient for a period of about eight

weeks. Patients will, of course, be under no financial obligation whatsoever

and, as I would prefer to see them at their homes, they will not even have to

travel. Patients will also be free to withdraw from the study at any time.

If you have any suitable patients on your records that may be interested in

participating in this project and you have no objection to such participation, I

would greatly appreciate it if you could contact me at the telephone number or

e-mail address listed below:

I thank you in anticipation of your assistance.

Yours sincerely

187

APPENDIX 8

Letter of consent

Dear

Your cooperation in my Master's research project will be greatly appreciated. I

am interested in finding out what effect your pain has on your day-to-day

living, as well as on your family and others with whom you come into regular

contact.

In exchange for your time and effort (which simply involves (a) seeing me

once weekly for about one hour and (b) completing a short questionnaire each

time), I hope to be able to help you to gradually gain some degree of relief

from your suffering through the use of hypnosis.

Please note:

1. This is a genuine research project. Your physiotherapist would not have

consented to your participation if this were not the case.

2. There is absolutely no financial commitment or obligation on your part

3. All information requested from you will be treated with the strictest of

confidence. Your name will not be used for purpose whatsoever, nor will it

be communicated to anyone not directly involved in the project

4. You are free to withdraw from the project at any time, although please

bear in mind that your cooperation may someday help other pain sufferers

such as yourself.

188

Please note that your signature below (a) frees me, as the researcher, from

any liability regarding the outcome of treatment and (b) grants me permission

to consult your physiotherapist in connection with your medical condition.

I look forward to meeting you and I hope our short association will be mutually

rewarding.

Yours sincerely

I agree to participate in this research project.

NAME (Please print): __________ _ DATE __ _

ADDRESS

TELEPHONE NUMBER ----- SIGNATURE -----

189

APPENDIX C

1. Throughout our lives, most of us have had pain from time to time (such as minor headaches, sprains, and toothaches). Have you had pain other than these everyday kinds of pain today?

2. On the diagram, shade in the areas where you feel pain. Put an X on the area that hurts the most.

3. Please rate your pain by circling the one number that best describes your pain at its l!mD.m in the last 24 hours.

4. Please rate your pain by circling the one nuimber that best describes your pain at its mlf.Din the last 24 hours.

5. Please rate your pain by circling the one number that best describes your pain on the~

6. Please rate your pain by circling the one number that tells how much pain you have

lllililll

8. ln the last 24 hours, how much relief have pain treatments or medications provided? Please circle the one percentage that most shows how much mim you have received.

9. Circle the one number that describes how, during the past 24 hours, pain has interfered with your:

hypnosis in the treatment of chronic pain-an …

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